Understanding safety culture in long-term care: a case study.

OBJECTIVES: This case study aimed to understand safety culture in a high-risk secured unit for cognitively impaired residents in a long-term care (LTC) facility. Specific objectives included the following: diagnosing the present level of safety culture maturity using the Patient Safety Culture Improvement Tool (PSCIT), examining the barriers to a positive safety culture, and identifying actions for improvement. METHODS: A mixed methods design was used within a secured unit for cognitively impaired residents in a Canadian nonprofit LTC facility. Semistructured interviews, a focus group, and the Modified Stanford Patient Safety Culture Survey Instrument were used to explore this topic. Data were synthesized to situate safety maturity of the unit within the PSCIT adapted for LTC. RESULTS: Results indicated a reactive culture, where safety systems were piecemeal and developed only in response to adverse events and/or regulatory requirements. A punitive regulatory environment, inadequate resources, heavy workloads, poor interdisciplinary collaboration, and resident safety training capacity were major barriers to improving safety. CONCLUSIONS: This study highlights the importance of understanding a unit's safety culture and identifies the PSCIT as a useful framework for planning future improvements to safety culture maturity. Incorporating mixed methods in the study of health care safety culture provided a good model that can be recommended for future use in research and LTC practice.

Getting to the root of the problem: health promotion strategies to address the social determinants of health.

Although extensive research shows that the social determinants of health influence the distribution and course of chronic diseases, there is little programming in public health that addresses the social determinants as a disease prevention strategy. This paper discusses different types of health promotion initiatives and differentiates them based on whether they attempt to impact intermediate (environmental) determinants of health or structural determinants of health. We argue for the importance of programming targeted at the structural determinants as opposed to programming targeted solely at the immediate environment. Specifically, the former has more potential to create significant improvements in health, contribute to long-term social change and increase health equity. We urge public health leaders to take this distinction into consideration during public health program planning, and to build capacity in the public health workforce to tackle structural mechanisms that lead to poor health and health inequities.

Uncovering tacit knowledge: a pilot study to broaden the concept of knowledge in knowledge translation.

BACKGROUND: All sectors in health care are being asked to focus on the knowledge-to-practice gap, or knowledge translation, to increase service effectiveness. A social interaction approach to knowledge translation assumes that research evidence becomes integrated with previously held knowledge, and practitioners build on and co-create knowledge through mutual interactions. Knowledge translation strategies for public health have not provided anticipated positive changes in evidence-based practice, possibly due in part to a narrow conceptualization of knowledge. More work is needed to understand the role of tacit knowledge in decision-making and practice. This pilot study examined how health practitioners applied tacit knowledge in public health program planning and implementation. METHODS: This study used a narrative approach, where teams from two public health units in Ontario, Canada were conveniently selected. Respondents participated in individual interviews and focus groups at each site. Questions were designed to understand the role of tacit knowledge as it related to the program planning process. Data were analyzed through a combination of content analysis and thematic comparison. RESULTS: The findings highlighted two major aspects of knowledge that arose: the use of tacit knowledge and the integration of tacit and explicit knowledge. Tacit knowledge included: past experiences, organization-specific knowledge, community contextual knowledge, and the recognition of the tacit knowledge of others. Explicit knowledge included: research literature, the Internet, popular magazines, formal assessments (surveys and interviews), legislation and regulations. Participants sometimes deliberately combined tacit and explicit knowledge sources in planning. CONCLUSIONS: This pilot demonstrated that front-line public health workers draw upon both tacit knowledge and explicit knowledge in their everyday lived reality. Further, tacit knowledge plays an important role in practitioners' interpretation and implementation of explicit research findings. This indicates a need to broaden the scope of knowledge translation to include other forms of knowledge beyond explicit knowledge acquired through research. Strategies that recognize and support the use of tacit knowledge, such as communities of practice or networks, may be important components of a comprehensive approach to knowledge translation. This study provides support for further investigation of the role of tacit knowledge in the planning and delivery of effective public health services.

Tobacco control interest groups and their influence on parliamentary committees in Canada.

OBJECTIVES: The aim of this study was to determine how tobacco control interest groups influence tobacco policy decision-making through submissions and presentations to parliamentary committees. METHODS: A qualitative content analysis was used to examine the presentations and submissions on tobacco-related legislation made to parliamentary committees between 1996 and 2004. The sample was identified from the public list of tobacco-related bills tabled in both the House of Commons and the Senate; the Government of Canada website and LEGISinfo were used to determine which committee reviewed the relevant bill. Committee clerks were asked to send submissions and presentations related to specific bills identified through LEGISinfo. Submissions and presentations were scanned and entered into QSR N6 software for coding. The coding instrument was adapted from previous studies employing qualitative content analysis. Montini and Bero's recommendations were used to evaluate the submissions and presentations. RESULTS: Tobacco control interest groups did present scientific evidence to support tobacco control. However, they underused credible witnesses to present information at meetings. The topics presented by tobacco control interests groups were usually relevant to the bill being discussed. DISCUSSION: Tobacco control interest groups employed some of the strategies suggested by Montini and Bero in their attempt to influence parliamentary committees through submissions and presentations. They did include scientific evidence in their submissions; however, they could improve their strategies in the area of using credible witnesses, such as scientists and medical experts. Incorporating Montini and Bero's recommendations into lobbying efforts may increase success in influencing committees.

Research and knowledge in Ontario tobacco control networks.

OBJECTIVES: This study sought to better understand the role of research knowledge in Ontario tobacco control networks by asking: 1) How is research managed; 2) How is research evaluated; and 3) How is research utilized? METHODS: This is a secondary analysis of a qualitative study based on individual semistructured interviews with 29 participants between January and May 2006. These participants were purposefully sampled from across four Ministries in the provincial government (n = 7), non-government (n = 15), and public health organizations (n = 7). Interviews were transcribed verbatim and coded and analyzed using QSR N7 qualitative software. This study received ethics approval from The University of Western Ontario Health Research Ethics Board. RESULTS: There exists a dissonance between the preference for peer-reviewed, unbiased, non-partisan knowledge to support claims and the need for fast, "real-time" information on which to base tobacco-related policy decisions. Second, there is a great deal of tacit knowledge held by experts within the Ontario tobacco control community. The networks among government, non-government, and public health organizations are the structures through which tacit knowledge is exchanged. These networks are dynamic, fluid and shifting. CONCLUSION: There exists a gap in the production and utilization of research knowledge for tobacco control policy. Tacit knowledge held by experts in Ontario tobacco control networks is an integral means of managing and evaluating research knowledge. Finally, this study builds on Weiss's concept of tactical model of evidence use by highlighting the utilization of research to enhance one's credibility.

Individual and regional determinants of mammography uptake.

BACKGROUND: Analysis of mammography utilization has traditionally been performed from an individual-level perspective. The purpose of this study was to explore the combined influence of individual- and regional-level determinants of mammography utilization. METHODS: Logistic hierarchical multilevel modelling was used to investigate the influences of region of residence and individual characteristics on mammography utilization. Socioeconomic status information about health planning regions was derived from the 1996 Canadian Census. Individual-level information was extracted from the 1996 National Population Health Survey. RESULTS: After controlling for individual-level education, regions with fewer high school graduates had lower levels of mammography utilization. A cross-level interaction between regional-level education and individual-level social involvement was found. Other individual-level variables associated with screening confirmed previous literature findings. CONCLUSION: Our findings suggest that higher levels of participation in social activities modify the detrimental influence on mammography utilization of living in a less educated region. This challenges the current focus of mammography screening research on individual-level determinants of uptake. Multilevel, synergistic strategies to possibly achieve higher levels of screening should be considered by health promotion program planners.

Multiple intervention research programs in community health.

The authors describe an organizing framework for multiple interventions in community health. The framework provides a foundation for programmatic research on multiple interventions and poses critical questions that need to be addressed in the next generation of research in this field. Multiple intervention programs are characterized by the use of multiple strategies targeted at multiple levels of the socio-ecological system and delivered to multiple target audiences. Consequently, they complement the growing literature on the broad determinants of health and health promotion. The authors describe a 4-stage framework and identify gaps and challenges in this field of research. There are 5 key research areas requiring concerted action; researchers must: examine nested determinants, develop integrated conceptual frameworks, examine ways to optimize synergies among interventions, describe spin-offs from multiple intervention programs, and monitor the sustainability of their impact.

Multilevel health promotion research: conceptual and analytical considerations.

Health promotion research is often conceptualized through the use of socioecological frameworks. This results in data or variables associated with multiple levels such as individual, community, and provincial. These data are nested, or clustered. In other words, multilevel health promotion research is based on the idea that community influences health, above and beyond one's individual characteristics or behaviours. These contextual effects can be analyzed rigorously using multilevel modelling (MLM), thus determining whether contextual effects are truly derived from context or are the result of residents' social profile. MLM also facilitates examination of cross-level interaction effects. The authors discuss conceptual and methodological issues related to multilevel research. While multilevel pathways to health outcomes have been suggested at the conceptual level, analytical techniques that produce only average overall effects fail to reveal the various other influences on health behaviour.