The contribution of primary care practitioners to interventions reducing loneliness and social isolation in older people-An integrative review.

BACKGROUND: Social connection is a fundamental human need. Its absence can lead to loneliness and social isolation, adversely impacting health and well-being. Given their regular contact and trusted relationships with older people, practitioners delivering community-based primary care are well-positioned to address this issue. However, their contribution to addressing loneliness and social isolation is unclear. AIM: This integrative review explores the contribution of the primary care workforce to interventions aimed at reducing loneliness and social isolation in community-dwelling older people. METHOD: Using an integrative review method, Scopus, Web of Science, CINAHL and PubMed were searched for original research published between 2000 and 2022. Fourteen papers reporting 13 primary studies were appraised for methodological quality and included in the review. Data were extracted into a summary table and analysed using thematic analysis. RESULTS: Included studies came from over six countries. Internationally, primary care services have diverse structures, funding and workforces influencing their response to loneliness and social isolation. All but one intervention was multi-component, with ten studies including a group-based activity and three providing primarily individual-level activities. Only six studies reported reductions in loneliness following the intervention. Three themes were identified: characteristics of interventions; implementation context, barriers and facilitators; and differing contributions of primary care practitioners in addressing loneliness and social isolation of older people. CONCLUSION: There is increasing demand and scope for primary care practitioners to assist lonely and socially isolated older people. It is important to understand how to equip and incentivise these practitioners to routinely identify, assess and respond to lonely and socially isolated older people despite varying implementation contexts. There is a need for further research that explores how the primary care team can be better utilised to deliver effective interventions that reduce the health impacts of loneliness and social isolation.

Application of mixture distributions for identifying thresholds of frequent and high inpatient mental health service use in longitudinal data.

BACKGROUND: There is a need for greater understanding about frequent and high use of inpatient mental health services, and those with ongoing increased needs. Most studies employ a threshold of frequent use (e.g. numbers of admissions) and high use (e.g. lengthy stays) without justification. AIMS: To identify model-driven thresholds for frequent/high inpatient mental health service use and contrast characteristics of patients identified using various models and thresholds. METHOD: Retrospective population-based study using 12 years of longitudinal data for 5631 patients admitted with a mental health diagnosis. Two-component negative binomial and poisson mixture (truncated/untruncated) models identified thresholds for frequent/high use in a 12-month period. RESULTS: The two-component negative binomial mixture model resulted in the best model fit. Using negative binomial-derived thresholds, 5.3% of patients had a period of frequent use (admitted six or more times), 15.8% of high use (hospitalised for 45 or more days) and 3.5% of heavy use (both frequent and high use). The prevalence of specific mental health disorders (e.g. mood disorder and schizophrenia) among frequent and high use cohorts varied across thresholds. CONCLUSIONS: This model-driven approach can be applied to identify thresholds in other cohorts. Threshold choice may depend on the magnitude and focus of potential interventions.

Evolution of a multilevel framework for health program evaluation.

A well-conceived evaluation framework increases understanding of a program's goals and objectives, facilitates the identification of outcomes and can be used as a planning tool during program development. Herein we describe the origins and development of an evaluation framework that recognises that implementation is influenced by the setting in which it takes place, the individuals involved and the processes by which implementation is accomplished. The framework includes an evaluation hierarchy that focuses on outcomes for consumers, providers and the care delivery system, and is structured according to six domains: program delivery, impact, sustainability, capacity building, generalisability and dissemination. These components of the evaluation framework fit into a matrix structure, and cells within the matrix are supported by relevant evaluation tools. The development of the framework has been influenced by feedback from various stakeholders, existing knowledge of the evaluators and the literature on health promotion and implementation science. Over the years, the framework has matured and is generic enough to be useful in a wide variety of circumstances, yet specific enough to focus data collection, data analysis and the presentation of findings.

Palliative Care Problem Severity Score: Reliability and acceptability in a national study.

BACKGROUND: The Palliative Care Problem Severity Score is a clinician-rated tool to assess problem severity in four palliative care domains (pain, other symptoms, psychological/spiritual, family/carer problems) using a 4-point categorical scale (absent, mild, moderate, severe). AIM: To test the reliability and acceptability of the Palliative Care Problem Severity Score. DESIGN: Multi-centre, cross-sectional study involving pairs of clinicians independently rating problem severity using the tool. SETTING/PARTICIPANTS: Clinicians from 10 Australian palliative care services: 9 inpatient units and 1 mixed inpatient/community-based service. RESULTS: A total of 102 clinicians participated, with almost 600 paired assessments completed for each domain, involving 420 patients. A total of 91% of paired assessments were undertaken within 2 h. Strength of agreement for three of the four domains was moderate: pain (Kappa = 0.42, 95% confidence interval = 0.36 to 0.49); psychological/spiritual (Kappa = 0.48, 95% confidence interval = 0.42 to 0.54); family/carer (Kappa = 0.45, 95% confidence interval = 0.40 to 0.52). Strength of agreement for the remaining domain (other symptoms) was fair (Kappa = 0.38, 95% confidence interval = 0.32 to 0.45). CONCLUSION: The Palliative Care Problem Severity Score is an acceptable measure, with moderate reliability across three domains. Variability in inter-rater reliability across sites and participant feedback indicate that ongoing education is required to ensure that clinicians understand the purpose of the tool and each of its domains. Raters familiar with the patient they were assessing found it easier to assign problem severity, but this did not improve inter-rater reliability.

Palliative Care Phase: inter-rater reliability and acceptability in a national study.

BACKGROUND: The concept of palliative care consisting of five distinct, clinically meaningful, phases (stable, unstable, deteriorating, terminal and bereavement) was developed in Australia about 20 years ago and is used routinely for communicating clinical status, care planning, quality improvement and funding. AIM: To test the reliability and acceptability of revised definitions of Palliative Care Phase. DESIGN: Multi-centre cross-sectional study involving pairs of clinicians independently rating patients according to revised definitions of Palliative Care Phase. SETTING/PARTICIPANTS: Clinicians from 10 Australian palliative care services, including 9 inpatient units and 1 mixed inpatient/community-based service. RESULTS: A total of 102 nursing and medical clinicians participated, undertaking 595 paired assessments of 410 patients, of which 90.7% occurred within 2 h. Clinicians rated 54.8% of patients in the stable phase, 15.8% in the unstable phase, 20.8% in the deteriorating phase and 8.7% in the terminal phase. Overall agreement between clinicians' rating of Palliative Care Phase was substantial (kappa = 0.67; 95% confidence interval = 0.61-0.70). A moderate level of inter-rater reliability was apparent across all participating sites. The results indicated that Palliative Care Phase was an acceptable measure, with no significant difficulties assigning patients to a Palliative Care Phase and a good fit between assessment of phase and the definition of that phase. The most difficult phase to distinguish from other phases was the deteriorating phase. CONCLUSION: Policy makers, funders and clinicians can be confident that Palliative Care Phase is a reliable and acceptable measure that can be used for care planning, quality improvement and funding purposes.

Advance care planning in palliative care: a national survey of health professionals and service managers.

OBJECTIVE: To identify the attitudes, knowledge and practices regarding advance care planning (ACP) in palliative care. METHODS: A nationwide online survey was distributed to Australian palliative care services associated with the Palliative Care Outcomes Collaboration (n=105). Seventy-three health professionals (HPs) and 59 service managers completed the survey. RESULTS: Regarding ACP, 51% of service managers reported relevant policies and procedures were in place in their service and 44% included ACP in job descriptions. Most HPs were confident in undertaking ACP, including initiating discussions with patients and complying with documents; however, only 44% reported receiving ACP specific training. Although 58% of HPs reported having conversations about ACP with more than 11 patients in the past 6 months, only 44% of managers report that it is offered to most patients. Thirty per cent of HPs were aware of others not adhering to patient wishes in the past 6 months and only 43% of HPs (and 37% of managers) believed ACP is done well within their service. CONCLUSIONS: This first national survey examining ACP in palliative care services demonstrates there is a need to improve systems to support ACP and to understand circumstances in which ACP wishes are not followed.

Palliative care health professionals' experiences of caring for patients with advance care directives.

OBJECTIVE: To explore the health professionals' (HPs) perceptions and experiences of advance care directives (ACDs) and advance care planning in Australian palliative care services. METHODS: A nationwide survey of 105 palliative care services was conducted, with two HPs from each service invited to participate. A qualitative analysis of open responses about advance care planning was undertaken. RESULTS: Sixty questionnaires were returned with open responses. Most responders were nurses (75%), aged ≥40 years (80%) and with a mean of 12 years palliative care experience. Data were grouped into four key themes: (1) the ACD; (2) the process of developing ACDs; (3) the process of using ACDs; and (4) the consequences of having ACDs. Participants were positive about advance care planning, commenting that ongoing communication about end-of-life care ensures mutual understanding between patients, family and HPs. Provision of care was considered easier and more efficient with an ACD in place. ACDs were perceived to reduce distrust and conflict between family, friends and HPs, and promote communication. Suboptimal documentation, clarity and explicitness limited the usefulness of ACDs when they were available. CONCLUSIONS: Advance care planning benefits HPs, patients and their family. To maximise these benefits, ACDs need to be clear, comprehensive, medically relevant and transportable documents.

Emergency department waiting times: Do the raw data tell the whole story?

OBJECTIVE: To determine whether there are real differences in emergency department (ED) performance between Australian states and territories. METHODS: Cross-sectional analysis of 2009-10 attendances at an ED contributing to the Australian non-admitted patient ED care database. The main outcome measure was difference in waiting time across triage categories. RESULTS: There were more than 5.8 million ED attendances. Raw ED waiting times varied by a range of factors including jurisdiction, triage category, geographic location and hospital peer group. All variables were significant in a model designed to test the effect of jurisdiction on ED waiting times, including triage category, hospital peer group, patient socioeconomic status and patient remoteness. When the interaction between triage category and jurisdiction entered the model, it was found to have a significant effect on ED waiting times (P<0.001) and triage was also significant (P<0.001). Jurisdiction was no longer statistically significant (P=0.248 using all triage categories and 0.063 using only Australian Triage Scale 2 and 3). CONCLUSIONS: Although the Council of Australian Governments has adopted raw measures for its key ED performance indicators, raw waiting time statistics are misleading. There are no consistent differences in ED waiting times between states and territories after other factors are accounted for. WHAT IS KNOWN ABOUT THE TOPIC? The length of time patients wait to be treated after presenting at an ED is routinely used to measure ED performance. In national health agreements with the federal government, each state and territory in Australia is expected to meet waiting time performance targets for the five ED triage categories. The raw data indicate differences in performance between states and territories. WHAT DOES THIS PAPER ADD? Measuring ED performance using raw data gives misleading results. There are no consistent differences in ED waiting times between the states and territories after other factors are taken into account. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Judgements regarding differences in performance across states and territories for triage waiting times need to take into account the mix of patients and the mix of hospitals.

Ageing with chronic conditions and older persons' experience of social connections: a qualitative descriptive study.

Background Chronic conditions may limit older peoples' social engagement and wellbeing. Reduced social connections can result in loneliness and social isolation. This study aimed to explore the experience of social connection in older people living with chronic conditions, and the factors influencing their social participation. Methods A purposive sample of 19 community-dwelling older Australians (mean age 75.5years) with one or more chronic conditions participated in a qualitative descriptive study. Semi-structured interviews explored participants' perceptions of their social connections and the potential impact of their chronic conditions. Views about the role of general practice in supporting older persons' wellbeing were discussed. Data were analysed inductively using thematic analysis. Results Five themes were identified: (1) the experience of loneliness, (2) managing diminishing social contacts, (3) living with chronic conditions, (4) barriers to social connection, and (5) facilitators of social connection. Participants felt that ageing with chronic conditions contributed to loss of function and independence, which limited social connections, and increased loneliness and social isolation. Barriers to social connections included issues with mobility, transport and forming new networks. Families were a primary support, with continued community engagement and general practice support crucial to staying well and socially connected. Conclusions Understanding older peoples' experiences, and the barriers and facilitators of social connections can guide clinicians' interventions. General practice is a promising intervention point because of its high use by those with chronic conditions to stay well. General practice nurses are well-placed to collaboratively address the barriers older people face in maintaining social connections.

Practice readiness of new graduate nurses and factors influencing practice readiness: A scoping review of reviews.

BACKGROUND: For many years there has been concern that new graduate nurses may not have been adequately prepared for the workplace, often framed in terms of whether they are work ready or practice ready and able to deal with the 'reality shock' of transitioning from student to clinician. This has prompted significant research to investigate the practice readiness of new graduate nurses. OBJECTIVES: Identify what is known about the practice readiness of new graduate nurses upon commencement of employment, how practice readiness changes over their first year of employment and explore the factors which influence practice readiness. DESIGN: Scoping review of existing reviews guided by the framework developed by Arksey and O'Malley, with search results based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. METHODS: MEDLINE, CINAHL, PsycINFO, Scopus and Web of Science were searched to identify literature reviews synthesising evidence about new graduate nurses, work readiness, practice readiness, competency and transition to practice. New graduate nurses were defined as nurses who were working in any clinical setting as a nurse within their first year of employment after graduation. Database searching was supplemented with snowball searching and limited to English language papers published between 2011 and 2020. Full-text copies of included reviews were imported into an NVivo (Version 12) database to facilitate analysis and synthesis of findings. RESULTS: Forty-five reviews were included. The findings indicate that transition is influenced by a wide range of intrapersonal, interpersonal and organisational factors, many of which are beyond the control of new graduate nurses. The findings also suggest that, overall, there are no major concerns about the practice readiness of new graduate nurses consistently supported by strong evidence. However, there is evidence to suggest that they 'lack confidence' during the first few months of employment. CONCLUSIONS: The 'receptivity' of the clinical environment to new graduate nurses appears to be a critical influence on their experience of transitioning from student to clinician and can also influence their readiness for the role of a registered nurse. Rather than focusing on the question of whether new graduate nurses are adequately prepared for the workplace, it may be time to shift the question to whether the workplace is ready to support new graduate nurses. The findings suggest two research priorities for advancing our understanding of workplace support for new graduate nurses.

Who needs, receives and misses out on palliative and end-of-life care? A population-based study to identify needs and gaps in a regional health service.

Objective The aim of this study was to assess the unmet need for palliative and other end-of-life care, as well as the sociodemographic and diagnostic factors associated with suboptimal access, among residents in an Australian region. Methods A cross-sectional descriptive and analytical study was performed using non-identifiable linked data from four administrative and two clinical datasets. The study population comprised 3175 patients aged ≥15 years who died in hospital in 2016 and 2017. The main outcome measures were the proportion of decedents potentially benefitting from end-of-life care and receiving end-of-life care. Results An estimated 74.8% of decedents needed palliative or other end-of-life care in the year before death. Approximately 13.3% did not receive any end-of-life care despite its potential benefit. The highest proportions with 'unmet need' were decedents with chronic obstructive pulmonary disease (31.0%) and heart failure (26.3%). Adjusting for sociodemographic and diagnostic factors, access was lowest among those aged <65 years (adjusted odds ratio (aOR) 0.44; 95% confidence interval (CI) 0.31-0.64) and those with heart failure (aOR 0.58; 95% CI 0.47-0.72). Conclusions Estimates of need and access provide a sound basis for planning local palliative and end-of-life care services. These methods can be used on an ongoing basis to monitor service delivery. What is known about this topic? There is a small but expanding literature on estimating the need for palliative care at a population level. There is a lack of data regarding access to palliative and other end-of-life care across multiple settings (e.g. home, specialist palliative care unit, hospital) and patient groups (e.g. defined by sociodemographics and diagnostics). What does this paper add? The study builds on previously used methods for estimating the need for palliative care, with some refinements, including the addition of 'other clinical indications' and the use of weights to derive more realistic estimates. The estimates of need are consistent with recent estimates from Australia and overseas, whereas the estimates of access are similar to a recent Australian estimate, but higher than estimates from overseas. The gaps in access are highest among those with the major types of chronic organ failure, particularly heart and respiratory. What are the implications for practitioners? The study demonstrates how routinely collected data at a regional level can be used to estimate need and access to palliative and end-of-life care, in the hospital and in the community. These methods of estimating need and unmet need can be used to inform the planning and development of services, as well as to monitor progress with implementation of changes in service provision.

The Clinical Services Redesign Program in New South Wales: perceptions of senior health managers.

OBJECTIVE: This study explores the views of senior managers regarding their experience of participating in the Clinical Services Redesign Program (CSRP) in New South Wales and the impact of that Program. METHODS: Semi-structured interviews were conducted in 2007 with 42 senior managers working in the NSW health system. RESULTS: Managers reported being increasingly oriented towards efficiency, achieving results and using data to support decision-making. The increased focus on managing performance was accompanied by concerns about the narrowness of the indicators being used to manage performance and how these are applied. The value placed by interviewees on the use of 'competition' as a lever for improving services varied. Leadership was repeatedly identified as important for long-term success and sustainability. No one was confident that the CSRP had yet been sufficiently embedded in day to day practice in order for it to keep going on its own. CONCLUSION: Our findings are generally consistent with the extensive literature on change management, performance management and leadership. Some cultural change has taken place in terms of observed patterns of behaviour but it is unrealistic to think that CSRP can on its own deliver the desired deeper cultural changes in the values and assumptions underpinning the NSW Health system. There is some evidence of dysfunctional aspects of performance management but no call for the focus on performance or redesign to be abandoned.

Linkage, coordination and integration: evidence from rural palliative care.

OBJECTIVE: Review the findings from the evaluations of three rural palliative care programs. DESIGN: Review by the authors of the original material from each evaluation. The conceptual framework for the review was provided by the work of Leutz, including his distinction between linkage, coordination and full integration. SETTING: Community-based palliative care in rural Australia. INTERVENTIONS: Fifteen projects across all six states of Australia that focused on integration between general practitioners and other community-based health providers. RESULTS: The projects set out to improve networking and collaboration between providers; improve coordination and integration of care for patients; reduce duplication of services; and achieve a multidisciplinary, collaborative approach to palliative care. The most common interventions were establishment of formal governance structures, provision of education programs, case conferencing, dissemination of information, development of formal arrangements, development of protocols and use of common clinical assessment tools. The terms 'integration' and 'coordination' were used frequently but without clear definitions. Coordination required someone specifically designated to do the coordinating, usually a nurse. Formal arrangements to improve linkage and coordination were difficult to maintain. The main mechanism to achieve full integration was the development of common clinical information systems. CONCLUSIONS: The 'laws' proposed by Leutz and the concepts of linkage, coordination and full integration provide a useful framework to understand the barriers to integrating GPs and other health providers. It is important to be clear on what level of integration is required. Improving links might be sufficient (and realistic), rather than striving for full integration.

Assessment of need and capacity to benefit for people with a disability requiring aids, appliances and equipment.

AIM: To develop an equitable system for allocating equipment, aids and appliances to adults with disabilities based on assessment of need and capacity to benefit for use by occupational therapists, who are the main professional group involved in assessing and prioritising applications. METHODS: An assessment tool was developed, pilot tested and field tested at four sites in New South Wales. Assessments were undertaken in parallel with existing systems. Feedback on use of the tool was obtained from those conducting the assessments and those making decisions to fund applications for equipment based on the assessments. RESULTS: One hundred and six assessments were undertaken. Applications for bed, sleeping and seating equipment and equipment to assist with mobility, toileting, showering and transfers accounted for 94.2% of equipment requested. Provision of equipment was expected to have greatest impact on the physical effort and safety of carers and the safety and quality of life of applicants. Regression analysis identified assessment items that explain variation between applicants and that can avoid unnecessary data collection. CONCLUSIONS: The assessment tool provides a standardised method for assessing requests for equipment based on the twin concepts of need and capacity to benefit. The results support the use of both concepts as the foundation of the assessment process. Further development is required, particularly to move to the next stage of using the assessment tool as the basis for prioritising applications for equipment.

Why patients attend emergency departments for conditions potentially appropriate for primary care: reasons given by patients and clinicians differ.

OBJECTIVES: To compare reasons identified by clinical staff for potential primary care attendances to the ED with those previously identified by patients. METHODS: Survey of staff and primary care patients in five ED in New South Wales, Australia using questionnaire based on reasons identified in published studies. RESULTS: Clinicians in the survey identify a broader spectrum of reasons for potential primary care cases presenting to the ED than the patients themselves report. Doctors reported on average 4.1 very important reasons and nurses 4.8 compared with patients 2.4 very important reasons. The main reasons identified by both doctors and nurses were similar and quite different to those identified by patients. Clinicians were more likely to emphasize cost and access issues rather than acuity and complexity issues. There was no difference within the clinician group between doctors and nurses nor by varying levels of experience. Furthermore doctors with significant experience in both primary care and emergency medicine did not differ from the overall clinicians' pattern. CONCLUSIONS: These data confirm that clinician perspectives on reasons for potential primary care patients' use of ED differ quite markedly from the perspectives of patients themselves. Those differences do not necessarily represent a punitive or blaming philosophy but will stem from the very different paradigms from which the two protagonists approach the interactions, reflecting the standard tension in a provider - consumer relationship. If policy is to be developed to improve system use and access, it must take both perspectives into account with respect to redesign, expectations and education.

Priority rating for community care.

This paper, which is an additional nosokinetics paper to accompany those presented in Aust Health Rev 31(1), reports on priority rating through a standardised community care assessment system, based on screening for functional abilities and incorporating additional indicators of need and risk. Routinely collected measures used to generate a priority rating have proven useful in clinical decision making and active demand management at the service entry point. Priority rating is a step towards a more equitable and efficient assessment system. Three examples of priority rating systems are described. The first is a generalist application now implemented in routine practice across multiple service types in the Queensland community care and community health system. The second, narrower in scope, was designed for the NSW Home Care Service, and is also being routinely collected. The third was pilot tested in a state-wide program to supply aids and appliances to disabled people and introduced the additional concept of "capacity to benefit". The case studies show how a technical and data-driven approach can be useful in guiding policy in a complex health care sector.

Attributes of innovations and approaches to scalability - lessons from a national program to extend the scope of practice of health professionals.

The context for the paper was the evaluation of a national program in Australia to investigate extended scopes of practice for health professionals (paramedics, physiotherapists, and nurses). The design of the evaluation involved a mixed-methods approach with multiple data sources. Four multidisciplinary models of extended scope of practice were tested over an 18-month period, involving 26 organizations, 224 health professionals, and 36 implementation sites. The evaluation focused on what could be learned to inform scaling up the extended scopes of practice on a national scale. The evaluation findings were used to develop a conceptual framework for use by clinicians, managers, and policy makers to determine appropriate strategies for scaling up effective innovations. Development of the framework was informed by the literature on the diffusion of innovations, particularly an understanding that certain attributes of innovations influence adoption. The framework recognizes the role played by three groups of stakeholders: evidence producers, evidence influencers, and evidence adopters. The use of the framework is illustrated with four case studies from the evaluation. The findings demonstrate how the scaling up of innovations can be influenced by three quite distinct approaches - letting adoption take place in an uncontrolled, unplanned, way; actively helping the process of adoption; or taking deliberate steps to ensure that adoption takes place. Development of the conceptual framework resulted in two sets of questions to guide decisions about scalability, one for those considering whether to adopt the innovation (evidence adopters), and the other for those trying to decide on the optimal strategy for dissemination (evidence influencers).

Peer review of adverse events - a perspective on Macarthur.

Recent investigations into the Macarthur Health Service have resulted in multiple reviews of a small number of cases. This article was prompted by a casual observation that these reviews have resulted in differing conclusions about what occurred in each case and what might have been done in response. The reliability of peer review is examined, together with the literature on the scale of adverse events and the issue of problem identification. Potential sources of bias and error during peer review are considered. Drawing on the lessons from the literature and the experience of Macarthur, suggestions are made to improve the identification and review of adverse events.

Mechanisms which help explain implementation of evidence-based practice in residential aged care facilities: a grounded theory study.

BACKGROUND: The context for the study was a nation-wide programme in Australia to implement evidence-based practice in residential aged care, in nine areas of practice, using a wide range of implementation strategies and involving 108 facilities. The study drew on the experiences of those involved in the programme to answer the question: what mechanisms influence the implementation of evidence-based practice in residential aged care and how do those mechanisms interact? METHODS: The methodology used grounded theory from a critical realist perspective, informed by a conceptual framework that differentiates between the context, process and content of change. People were purposively sampled and invited to participate in semi-structured interviews, resulting in 44 interviews involving 51 people during 2009 and 2010. Participants had direct experience of implementation in 87 facilities, across nine areas of practice, in diverse locations. Sampling continued until data saturation was reached. The quality of the research was assessed using four criteria for judging trustworthiness: credibility, transferability, dependability and confirmability. RESULTS: Data analysis resulted in the identification of four mechanisms that accounted for what took place and participants' experiences. The core category that provided the greatest understanding of the data was the mechanism On Common Ground, comprising several constructs that formed a 'common ground' for change to occur. The mechanism Learning by Connecting recognised the ability to connect new knowledge with existing practice and knowledge, and make connections between actions and outcomes. Reconciling Competing Priorities was an ongoing mechanism whereby new practices had to compete with an existing set of constantly shifting priorities. Strategies for reconciling priorities ranged from structured approaches such as care planning to more informal arrangements such as conversations during daily work. The mechanism Exercising Agency bridged the gap between agency and action. It was the human dimension of change, both individually and collectively, that made things happen. CONCLUSIONS: The findings are consistent with the findings of others, but fit together in a novel way and add to current knowledge about how to improve practices in residential aged care. Each of the four mechanisms is necessary but none are sufficient for implementation to occur.

Literature review to identify factors that support implementation of evidence-based practice in residential aged care.

The aim was to undertake a review of the literature on change management, quality improvement, evidence-based practice and diffusion of innovations to identify key factors that might influence the uptake and continued use of evidence in residential aged care. The key factors will be used to shape and inform the evaluation of the Encouraging Best Practice in Residential Aged Care Program which commenced in Australia in 2007. MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews were searched using combinations of search terms. Searching focused on existing literature reviews, discussions of relevant conceptual and theoretical frameworks and primary studies that have examined the implementation of evidence-based practice in residential aged care. Keyword searching was supplemented with snowball searching (following up on the references cited in the papers identified by the search), searching by key authors in the field and hand searching of a small number of journals. In general, the period covered by the searches was from 2002 to 2008. The findings from the literature are often equivocal. Analysis and consolidation of factors derived from the literature that might influence the implementation of evidence-based practice resulted in the identification of eight factors: (i) a receptive context for change; (ii) having a model of change to guide implementation; (iii) adequate resources; (iv) staff with the necessary skills; (v) stakeholder engagement, participation and commitment; (vi) the nature of the change in practice; (vii) systems in place to support the use of evidence; and (viii) demonstrable benefits of the change. Most of the literature included in the review is from studies in healthcare and hence the generalisability to residential aged care is largely unknown. However, the focus of this research is on clinical care, within the context of residential aged care, hence the healthcare literature is relevant. The factors are relatively broad and cover the evidence itself, the process of implementation, the context within which evidence will be implemented and the systems and resources to support implementation. It is likely that the factors are not independent of each other. The set of factors will be refined over the course of the evaluation.