Implementing pelvic floor muscle training for women with pelvic organ prolapse: a realist evaluation of different delivery models.

BACKGROUND: Pelvic Floor Muscle Training (PFMT) has been shown to be effective for pelvic organ prolapse in women, but its implementation in routine practice is challenging due to lack of adequate specialist staff. It is important to know if PFMT can be delivered by different staff skill mixes, what barriers and facilitators operate in different contexts, what strategies enable successful implementation and what are the underlying mechanisms of their action. PROPEL intervention was designed to maximise the delivery of effective PFMT in the UK NHS using different staff skill mixes. We conducted a realist evaluation (RE) of this implementation to understand what works, for whom, in what circumstances and why. METHODS: Informed by the Realist and RE-AIM frameworks, the study used a longitudinal, qualitative, multiple case study design. The study took place in five, purposively selected, diverse NHS sites across the UK and proceeded in three phases to identify, test and refine a theory of change. Data collection took place at 4 time points over an 18 month implementation period using focus groups and semi-structured interviews with a range of stakeholders including service leads/managers, senior practitioners, newly trained staff and women receiving care in the new service models. Data were analysed using thematic framework approach adapted to identify Context, Mechanism and Outcome (CMO) configurations of the RE. RESULTS: A heightened awareness of the service need among staff and management was a mechanism for change, particularly in areas where there was a shortage of skilled staff. In contrast, the most established specialist physiotherapist-delivered PFMT service activated feelings of role protection and compromised quality, which restricted the reach of PFMT through alternative models. Staff with some level of prior knowledge in women's health and adequate organisational support were more comfortable and confident in new role. Implementation was seamless when PFMT delivery was incorporated in newly trained staff's role and core work. CONCLUSION: Roll-out of PFMT delivery through different staff skill mixes is possible when it is undertaken by clinicians with an interest in women's health, and carefully implemented ensuring adequate levels of training and ongoing support from specialists, multi-disciplinary teams and management.

Women's experiences of receiving care for pelvic organ prolapse: a qualitative study.

BACKGROUND: Pelvic organ prolapse is a common urogenital condition affecting 41-50% of women over the age of 40. To achieve early diagnosis and appropriate treatment, it is important that care is sensitive to and meets women's needs, throughout their patient journey. This study explored women's experiences of seeking diagnosis and treatment for prolapse and their needs and priorities for improving person-centred care. METHODS: Twenty-two women receiving prolapse care through urogynaecology services across three purposefully selected NHS UK sites took part in three focus groups and four telephone interviews. A topic guide facilitated discussions about women's experiences of prolapse, diagnosis, treatment, follow-up, interactions with healthcare professionals, overall service delivery, and ideals for future services to meet their needs. Data were analysed thematically. RESULTS: Three themes emerged relating to women's experiences of a) Evaluating what is normal b) Hobson's choice of treatment decisions, and c) The trial and error of treatment and technique. Women often delayed seeking help for their symptoms due to lack of awareness, embarrassment and stigma. When presented to GPs, their symptoms were often dismissed and unaddressed until they became more severe. Women reported receiving little or no choice in treatment decisions. Choices were often influenced by health professionals' preferences which were subtly reflected through the framing of the offer. Women's embodied knowledge of their condition and treatment was largely unheeded, resulting in decisions that were inconsistent with women's preferences and needs. Physiotherapy based interventions were reported as helping women regain control over their symptoms and life. A need for greater awareness of prolapse and physiotherapy interventions among women, GPs and consultants was identified alongside greater focus on prevention, early diagnosis and regular follow-up. Greater choice and involvement in treatment decision making was desired. CONCLUSIONS: As prolapse treatment options expand to include more conservative choices, greater awareness and education is needed among women and professionals about these as a first line treatment and preventive measure, alongside a multi-professional team approach to treatment decision making. Women presenting with prolapse symptoms need to be listened to by the health care team, offered better information about treatment choices, and supported to make a decision that is right for them.

PROPEL: implementation of an evidence based pelvic floor muscle training intervention for women with pelvic organ prolapse: a realist evaluation and outcomes study protocol.

BACKGROUND: Pelvic Organ Prolapse (POP) is estimated to affect 41%-50% of women aged over 40. Findings from the multi-centre randomised controlled "Pelvic Organ Prolapse PhysiotherapY" (POPPY) trial showed that individualised pelvic floor muscle training (PFMT) was effective in reducing symptoms of prolapse, improved quality of life and showed clear potential to be cost-effective. However, provision of PFMT for prolapse continues to vary across the UK, with limited numbers of women's health physiotherapists specialising in its delivery. Implementation of this robust evidence from the POPPY trial will require attention to different models of delivery (e.g. staff skill mix) to fit with differing care environments. METHODS: A Realist Evaluation (RE) of implementation and outcomes of PFMT delivery in contrasting NHS settings will be conducted using multiple case study sites. Involving substantial local stakeholder engagement will permit a detailed exploration of how local sites make decisions on how to deliver PFMT and how these lead to service change. The RE will track how implementation is working; identify what influences outcomes; and, guided by the RE-AIM framework, will collect robust outcomes data. This will require mixed methods data collection and analysis. Qualitative data will be collected at four time-points across each site to understand local contexts and decisions regarding options for intervention delivery and to monitor implementation, uptake, adherence and outcomes. Patient outcome data will be collected at baseline, six months and one year follow-up for 120 women. Primary outcome will be the Pelvic Organ Prolapse Symptom Score (POP-SS). An economic evaluation will assess the costs and benefits associated with different delivery models taking account of further health care resource use by the women. Cost data will be combined with the primary outcome in a cost effectiveness analysis, and the EQ-5D-5L data in a cost utility analysis for each of the different models of delivery. DISCUSSION: Study of the implementation of varying models of service delivery of PFMT across contrasting sites combined with outcomes data and a cost effectiveness analysis will provide insight into the implementation and value of different models of PFMT service delivery and the cost benefits to the NHS in the longer term.

A creative approach to the development of an agenda for knowledge utilization: outputs from the 11th international knowledge utilization colloquium (KU 11).

A group of researchers and practitioners interested in advancing knowledge utilization met as a colloquium in Belfast (KU 11) and used a "world café" approach to exploit the social capital and shared understanding built up over previous events to consider the research and practice agenda. We considered three key areas of relevance to knowledge use: (1) understanding the nature of research use, influence and impact; (2) blended and collaborative approaches to knowledge production and use; and (3) supporting sustainability and spread of evidence-informed innovations. The approach enabled the development of artifacts that reflected the three areas and these were analyzed using a creative hermeneutic approach. The themes that emerged and which are outlined in this commentary are not mutually exclusive. There was much overlap in the discussions and therefore of the themes, reflecting the complex nature of knowledge translation work. The agenda that has emerged from KU 11 also reflects the participatory and creative approach in which the meeting was structured and focused, and therefore emphasizes the processual, relational and contingent nature of some of the challenges we face. The past 20 years has seen an explosion in activity around understanding KU, and we have learned much about the difficulties. Whilst the agenda for the next decade may be becoming clearer, colloquia such as KU 11, using creative and engaging approaches, have a key role to play in dissecting, articulating and sharing that agenda. In this way, we also build an ever-expanding international community that is dedicated to working towards increasing the chances of success for better patient care.

An exploration of the roles of nurse managers in evidence-based practice implementation.

BACKGROUND: Internationally, nurses face ongoing difficulties in making a reality of evidence-based practice. Existing studies suggest that nurse managers (NMs) should play a key role in leading and facilitating evidence-based practice, but the nature of this role has not yet been fully explored or articulated. This is one of the first studies to investigate the roles of NMs in evidence-based practice implementation. METHODOLOGY AND METHODS: Using a case study approach the study explores five propositions in relation to the NMs' potential evidence-based practice role and the extent to which their attitudes, knowledge, and skills support such a role. In doing so, it draws on interviews (n= 51), documentary analysis and observational data. FINDINGS: Data analysis reveals that the role of NMs in facilitating evidence-based practice is under-articulated, largely passive and currently limited by competing demands. Progress in implementing evidence-based practice in the case study sites is largely explained by factors other than the role played by NMs. As such, the findings expose significant discrepancies between NMs' actual roles and those espoused in the literature as being necessary. Contextual factors are important and it is clear that the role of the contemporary NM places considerable emphasis on management and administration to the detriment of clinical practice concerns. CONCLUSIONS: The study reveals that NMs are only involved in evidence-based practice implementation in a passive role, not the full engagement described in the literature as being necessary. This study adds previously lacking detail of the roles of NMs. It elucidates why exhortations to NMs to become more involved in evidence-based practice implementation are ineffective without action to address the problems identified.

Tracing and identifying the impact of evidence-use of a modified pipeline model.

AIM: This paper opens up a discussion about effective ways of tracing and identifying impact of evidence implementation in the field of nursing, through the use of Nutley et al.'s concept of an impact continuum, and Glasziou's Pipeline Model. APPROACH: Work to date on improving and evaluating the use of evidence in health care settings has tended to focus on evidence implementation as an endpoint or entity, often seen and measured in terms of change in practice. However, the direct application of evidence to practice is not straightforward. Glasziou's Pipeline Model of the different stages through which evidence flows, in the process of implementation, is critically reviewed in relation to five key issues: the type of evidence entering the pipeline; the linearity of the model; leakages and blockages in the pipeline; levels of impact; and impact measurement. The Pipeline Model is then combined with Nutley et al.'s continuum of impacts in order to present a Modified Pipeline Model. DISCUSSION AND CONCLUSIONS: The Modified Pipeline Model enables evidence implementation to be viewed as a process rather than an entity in itself, which in turn enables longitudinal assessment of barriers and facilitators to evidence "flow." By flow we mean the way in which evidence is transferred from reporting or publication stages to patient outcomes. It also allows identification of the multiple impacts that can occur through the process of evidence implementation, which may be impact on the way the nurse thinks about practice to the healing rate of a leg ulcer. Finally, the Modified Model raises the issue of impacts beyond the pipeline, that is, those outcomes for patients that result from adherence to evidence-based care. This Modified Pipeline Model thus has the potential to support individuals and organizations in enhanced implementation planning, evaluation and management.

The Learning Practice Inventory: diagnosing and developing Learning Practices in the UK.

BACKGROUND AND SETTING: This paper outlines the development of a diagnostic tool to help Primary Care general practitioner (GP) Practices diagnose the extent to which they are developing effective techniques for collective learning and if their Practice culture supports innovation. This project is undertaken by the University of St Andrews and NHS Education for Scotland. METHODS: Based on Learning Organization and Organizational Learning theory, and using a modified Behaviourally Anchored Rating Scale, the Learning Practice Inventory (LPI) identifies attitudes, behaviours, processes, systems and organizational arrangements associated with being a Learning Practice. The LPI is a self-assessment, fixed-choice, survey-feedback tool that surveys all Practice members. RESULTS: The survey-feedback tool empowers Practice members to view, assess and prioritize the developments they wish to make collectively to Practice life. The LPI assumes complexity and non-linearity in change processes, used longitudinally it tracks the impact of change on Practice life through time. Practitioners and Practices involved in its development give favourable feedback on the tool, and its potential usefulness. DISCUSSION: This contributes to our wider understanding in three main ways: first, it applies the ideas of Learning Organizations and Organizational Learning to health care settings. Second, as a practical advance, the tool assumes complexity, non-linearity and systemic knock-on effects during change in Primary Care. Third, it offers practitioners who work together the opportunity to share knowledge and learning in practical ways helping them to change by themselves and for themselves and their patients.

Delivering feedback on learning organization characteristics--using a Learning Practice Inventory.

RATIONALE, AIMS AND OBJECTIVES: Learning is recognized to be at the heart of the quality improvement process in the National Health Service (NHS). However, the challenge will be how to ensure that learning becomes embedded within the NHS culture. The aim of this study is to identify a robust feedback process and format in which practices could receive data on their responses to a Learning Practice Inventory (a diagnostic instrument designed to identify a practice's capacity for collective learning and change). METHOD: Five practices volunteered to test the instrument, and it was distributed to all members of the primary care team. A process was worked through to identify different formats for presenting scores within and between practices. The preferred method of data presentation was sought, and an evaluation gathered information on the preferred form of feedback, the usefulness of the data, the clarity of the questions and the level of interest in receiving further information. RESULTS: Eighty-five staff from five practices completed the questionnaire, and 61 individuals completed the evaluation forms. In most cases, there was a spread of scores by staff within practices and across the scale of 1-10. Medians were clustered at the learning practice end for all five practices. However, despite this skew, there were sometimes quite large differences between practices in their median scores. CONCLUSION: Our study suggests that a robust feedback process on collective capacity for learning and change can be identified that is useful and feasible. A key implication is that some form of educational support is required, and this work will take place as part of an ongoing programme of research by the authors.

Time, fear and transformation: Student nurses' experiences of doing a practicum (quality improvement project) in practice.

BACKGROUND: Improving and sustaining quality in healthcare continues to be a global challenge, resulting in the necessity of developing quality improvement (QI) skills and knowledge to use in practice. This paper reports student nurses' experiences of conducting a quality improvement project (Practicum) as a compulsory assessment whilst on clinical placement areas across Scotland. METHODS: Telephone and face-to-face interviews (n = 18) were conducted using a semi-structured interview schedule. Discussions were transcribed verbatim and data were analysed thematically. Data were extracted from Practicum assignments (n = 50). RESULTS: Three key themes emerged from the analysis: 1) Time; students highlighted the necessity of time in practice areas to acclimatise, socialise and conduct the Practicum. Timing of the Practicum within the curriculum was also important. 2) Fear; was experienced by many students at the perceived enormity of the assignment, the bravery needed to attempt to change practice and the adjustment to a unique type of assignment. 3) Transformation; students shared their shifted perceptions on completing a Practicum, including a sense of achievement and acknowledgement of key improvement skills for the future. CONCLUSIONS: Student nurses need to be stretched beyond their comfort zones to rise to the challenge of the Practicum, whilst ensuring adequate support mechanisms are in place from a range of sources.

Collective action for implementation: a realist evaluation of organisational collaboration in healthcare.

BACKGROUND: Increasingly, it is being suggested that translational gaps might be eradicated or narrowed by bringing research users and producers closer together, a theory that is largely untested. This paper reports a national study to fill a gap in the evidence about the conditions, processes and outcomes related to collaboration and implementation. METHODS: A longitudinal realist evaluation using multiple qualitative methods case studies was conducted with three Collaborations for Leadership in Applied Health Research in Care (England). Data were collected over four rounds of theory development, refinement and testing. Over 200 participants were involved in semi-structured interviews, non-participant observations of events and meetings, and stakeholder engagement. A combined inductive and deductive data analysis process was focused on proposition refinement and testing iteratively over data collection rounds. RESULTS: The quality of existing relationships between higher education and local health service, and views about whether implementation was a collaborative act, created a path dependency. Where implementation was perceived to be removed from service and there was a lack of organisational connections, this resulted in a focus on knowledge production and transfer, rather than co-production. The collaborations' architectures were counterproductive because they did not facilitate connectivity and had emphasised professional and epistemic boundaries. More distributed leadership was associated with greater potential for engagement. The creation of boundary spanning roles was the most visible investment in implementation, and credible individuals in these roles resulted in cross-boundary work, in facilitation and in direct impacts. The academic-practice divide played out strongly as a context for motivation to engage, in that 'what's in it for me' resulted in variable levels of engagement along a co-operation-collaboration continuum. Learning within and across collaborations was patchy depending on attention to evaluation. CONCLUSIONS: These collaborations did not emerge from a vacuum, and they needed time to learn and develop. Their life cycle started with their position on collaboration, knowledge and implementation. More impactful attempts at collective action in implementation might be determined by the deliberate alignment of a number of features, including foundational relationships, vision, values, structures and processes and views about the nature of the collaboration and implementation.

"Horses for Courses": Comment on "Translating Evidence Into Healthcare Policy and Practice: Single Versus Multi-Faceted Implementation Strategies - Is There a Simple Answer to a Complex Question?".

This commentary considers the vexed question of whether or not we should be spending time and resources on using multifaceted interventions to undertake implementation of evidence in healthcare. A review of systematic reviews has suggested that simple interventions may be just as effective as those taking a multifaceted approach. Taking cognisance of the Promoting Action on Research Implementation in Health Services (PARIHS) framework this commentary takes account of the evidence, context and facilitation factors in undertaking implementation. It concludes that a 'horses for courses' approach is necessary meaning that the specific implementation approach should be selected to fit the implementation task in hand whether it be a single or multifaceted approach and reviewed on an individual basis.

Introducing the Learning Practice--I. The characteristics of Learning Organizations in Primary Care.

RATIONALE, AIMS AND OBJECTIVES: This paper is the first of three related papers exploring the ways in which the principles of Learning Organizations (LOs) could be applied in Primary Care settings at the point of service delivery. Here we introduce the notion of the Learning Practice (LP) and outline the characteristics and nature of an LP, exploring cultural and structural factors in detail. METHODS: Drawing upon both theoretical concepts and empirical research into LOs in health care settings, the format, focus and feasibility of an LP is explored. RESULTS AND CONCLUSIONS: Characteristics of LPs include flatter team-based structures that prioritize learning and empowered change, involve staff and are open to suggestions and innovation. Potential benefits include: timely changes in service provision that are realistic, acceptable, sustainable, and owned at practitioner level; smoother interprofessional working; and fast flowing informal communication backed up by records of key decisions to facilitate permanent learning. Critical comment on potential pitfalls and practical difficulties highlights features of the present system that hinder development: tightly defined roles; political behaviours and individual-oriented support systems; plus the ongoing difficulties involved in tolerating errors (whilst people learn). This paper contributes to the wider quality improvement debate in the area in three main ways. First, by locating Government's desires to create health systems capable of learning within the theoretical and empirical evidence on LOs. Second, it suggests what an LP could be like and how its culture and structures might benefit both staff and patients in addition to meeting externally driven reforms and health priorities. Third, it extends the application of LO concepts to the health care sector locating the principles in bottom-up change.

Introducing the Learning Practice--II. Becoming a Learning Practice.

RATIONALE, AIMS AND OBJECTIVES: This paper is the second of three related papers exploring the ways in which the principles of Learning Organizations (LOs) could be applied in Primary Care settings at the point of service delivery. METHODS: Based on a theoretical and empirical review of available evidence, here we introduce the process by which a Practice can start to become a Learning Practice (LP). RESULTS AND CONCLUSIONS: Steps taken to enhance both individual and organizational learning begin the process of moving towards a learning culture. Attention is given to the routines that can be established within the practice to make learning systematically an integral part of what the practice does. This involves focusing on all three of single-, double- and triple-loop learning. Within the paper, a distinction is made between individual, collective and organizational learning. We argue that individual and collective learning may be easier to achieve than organizational learning as processes and systems already exist within the Health Service to facilitate personal learning and development with some opportunities for collective and integrated learning and working. However, although organizational learning needs to spread beyond the LP to the wider Health Service to inform future training courses, policy and decision-making, there currently seem to be few processes by which this might be achieved. This paper contributes to the wider quality improvement debate in three main ways. First, by reviewing existing theoretical and empirical material on LOs in health care settings it provides both an informed vision and a set of practical guidelines on the ways in which a Practice could start to effect its own regime of learning, innovation and change. Second, it highlights the paucity of opportunities individual general practitioner practices have to share their learning more widely. Thirdly, it adds to the evidence base on how to apply LO theory and activate learning cultures in health care settings.

Introducing the Learning Practice--III. Leadership, empowerment, protected time and reflective practice as core contextual conditions.

RATIONALE, AIMS AND OBJECTIVES: This paper is the third of three related papers exploring the ways in which the principles of Learning Organizations (LOs) could be applied in Primary Care settings at the point of service delivery. METHODS: Here we provide a systematic literature review of contextual factors that either play a key role in providing a facilitative context for a Learning Practice or manifest themselves as barriers to any Practice's attempts to develop a learning culture. RESULTS AND CONCLUSION: Core contextual conditions are identified as, first, the requirement for strong and visionary leadership. Leaders who support and develop others, ask challenging questions, are willing to be learners themselves, see possibilities and make things happen, facilitate learning environments. The second core condition is the involvement and empowerment of staff where changes grow from the willing participation of all concerned. The third prerequisite is the setting-aside of times and places for learning and reflection. This paper contributes to the wider quality improvement debate in three main ways. First, by highlighting the local contextual issues that are most likely to impact on the success or failure of a Practice's attempts to work towards a learning culture. Second, by demonstrating that the very same factors can either help or hinder depending on how they are manifest and played out in context. Third, it adds to the evidence available to support the case for LOs in health care settings.

Collaborative action around implementation in Collaborations for Leadership in Applied Health Research and Care: towards a programme theory.

OBJECTIVES: In theory, greater interaction between researchers and practitioners should result in increased potential for implementation. However, we know little about whether this is the case, or what mechanisms might operate to make it happen. This paper reports findings from a study that is identifying and tracking implementation mechanisms, processes, influences and impacts in real time, over time in the Collaborations for Leadership in Applied Health Research and Care (CLAHRCs). METHODS: This is a longitudinal, realist evaluation case study. The development of the conceptual framework and initial hypotheses involved literature reviewing and stakeholder consultation. Primary data were collected through interviews, observations and documents within three CLAHRCs, and analysed thematically against the framework and hypotheses. RESULTS: The first round of data collection shows that the mechanisms of collaborative action, relationship building, engagement, motivation, knowledge exchange and learning are important to the processes and outcomes of CLAHRCs' activity, including their capacity for implementation. These mechanisms operated in different contexts such as competing agendas, availability of resources and the CLAHRCs' brand. Contexts and mechanisms result in different impact, including the CLAHRCs' approach to implementation, quality of collaboration, commitment and ownership, and degree of sharing and managing knowledge. CONCLUSION: Emerging features of a middle range theory of implementation within collaboration include alignment in organizational structures and cognitive processes, history of partnerships, responsiveness and resilience in rapidly changing contexts. CLARHCs' potential to mobilize knowledge may be further realized by how they develop insights into their function as collaborative entities.