Exploring factors that influence the spread and sustainability of a dysphagia innovation: an instrumental case study.

BACKGROUND: Swallowing difficulties challenge patient safety due to the increased risk of malnutrition, dehydration and aspiration pneumonia. A theoretically driven study was undertaken to examine the spread and sustainability of a locally developed innovation that involved using the Inter-Professional Dysphagia Framework to structure education for the workforce. A conceptual framework with 3 spread strategies (hierarchical control, participatory adaptation and facilitated evolution) was blended with a processual approach to sustaining organisational change. The aim was to understand the processes, mechanism and outcomes associated with the spread and sustainability of this safety initiative. METHODS: An instrumental case study, prospectively tracked a dysphagia innovation for 34 months (April 2011 to January 2014) in a large health care organisation in England. A train-the-trainer intervention (as participatory adaptation) was deployed on care pathways for stroke and fractured neck of femur. Data were collected at the organisational and clinical level through interviews (n = 30) and document review. The coding frame combined the processual approach with the spread mechanisms. Pre-determined outcomes included the number of staff trained about dysphagia and impact related to changes in practice. RESULTS: The features and processes associated with hierarchical control and participatory adaptation were identified. Leadership, critical junctures, temporality and making the innovation routine were aspects of hierarchical control. Participatory adaptation was evident on the care pathways through stakeholder responses, workload and resource pressures. Six of the 25 ward based trainers cascaded the dysphagia training. The expected outcomes were achieved when the top-down mandate (hierarchical control) was supplemented by local engagement and support (participatory adaptation). CONCLUSIONS: Frameworks for spread and sustainability were combined to create a 'small theory' that described the interventions, the processes and desired outcomes a priori. This novel methodological approach confirmed what is known about spread and sustainability, highlighted the particularity of change and offered new insights into the factors associated with hierarchical control and participatory adaptation. The findings illustrate the dualities of organisational change as universal and context specific; as particular and amendable to theoretical generalisation. Appreciating these dualities may contribute to understanding why many innovations fail to become routine.

Using the Knowledge to Action Framework in practice: a citation analysis and systematic review.

BACKGROUND: Conceptual frameworks are recommended as a way of applying theory to enhance implementation efforts. The Knowledge to Action (KTA) Framework was developed in Canada by Graham and colleagues in the 2000s, following a review of 31 planned action theories. The framework has two components: Knowledge Creation and an Action Cycle, each of which comprises multiple phases. This review sought to answer two questions: 'Is the KTA Framework used in practice? And if so, how?' METHODS: This study is a citation analysis and systematic review. The index citation for the original paper was identified on three databases-Web of Science, Scopus and Google Scholar-with the facility for citation searching. Limitations of English language and year of publication 2006-June 2013 were set. A taxonomy categorising the continuum of usage was developed. Only studies applying the framework to implementation projects were included. Data were extracted and mapped against each phase of the framework for studies where it was integral to the implementation project. RESULTS: The citation search yielded 1,787 records. A total of 1,057 titles and abstracts were screened. One hundred and forty-six studies described usage to varying degrees, ranging from referenced to integrated. In ten studies, the KTA Framework was integral to the design, delivery and evaluation of the implementation activities. All ten described using the Action Cycle and seven referred to Knowledge Creation. The KTA Framework was enacted in different health care and academic settings with projects targeted at patients, the public, and nursing and allied health professionals. CONCLUSIONS: The KTA Framework is being used in practice with varying degrees of completeness. It is frequently cited, with usage ranging from simple attribution via a reference, through informing planning, to making an intellectual contribution. When the framework was integral to knowledge translation, it guided action in idiosyncratic ways and there was theory fidelity. Prevailing wisdom encourages the use of theories, models and conceptual frameworks, yet their application is less evident in practice. This may be an artefact of reporting, indicating that prospective, primary research is needed to explore the real value of the KTA Framework and similar tools.

Evaluating a novel approach to enhancing dysphagia management: workplace-based, blended e-learning.

AIMS AND OBJECTIVES: To evaluate the learning effect and resource use cost of workplace-based, blended e-learning about dysphagia for stroke rehabilitation nurses. BACKGROUND: Dysphagia is a potentially life-threatening problem that compromises quality of life. In many countries, nurses play a crucial role in supporting the management of patients with swallowing problems, yet the literature reports a need for training. DESIGN: A single-group, pre- and post-study with mixed methods. METHODS: Each blended e-learning session comprised a needs analysis, e-learning programmes, practical skills about modifying fluids and action planning to transfer learning into practice. Participants were the population of registered nurses (n = 22) and healthcare assistants (n = 10) on a stroke rehabilitation ward in a large, teaching hospital in England between August 2010-March 2011. Data collection comprised observation (34 hours), questionnaires administered at four time points to examine change in attitude, knowledge and practice, and estimating the resource use cost for the service. Nonparametric tests and content analysis were used to analyse the data. RESULTS: All participants achieved a nationally recognised level of competence. The learning effect was evident on the post- and follow-up measures, with some items of dysphagia knowledge and attitude achieving significance at the p ≤ 0·05 level. The most common self-reported changes in practice related to medicines management, thickening fluids and oral hygiene. The resource use cost was estimated at £2688 for 108 hours training. CONCLUSIONS: Workplace-based, blended e-learning was an acceptable, cost effective way of delivering essential clinical knowledge and skills about dysphagia. RELEVANCE TO CLINICAL PRACTICE: Dysphagia should be viewed as a patient safety issue because of the risks of malnutrition, dehydration and aspiration pneumonia. As such, it is pertinent to many members of the interdisciplinary team. Consideration should be given to including dysphagia management in initial education and continuing professional development programmes.

Exploring scale-up, spread, and sustainability: an instrumental case study tracing an innovation to enhance dysphagia care.

BACKGROUND: Adoption, adaptation, scale-up, spread, and sustainability are ill-defined, undertheorised, and little-researched implementation science concepts. An instrumental case study will track the adoption and adaptation, or not, of a locally developed innovation about dysphagia as a patient safety issue. The case study will examine a conceptual framework with a continuum of spread comprising hierarchical control or 'making it happen', participatory adaptation or 'help it happen', and facilitated evolution or 'let it happen'. METHODS: This case study is a prospective, longitudinal design using mixed methods. The fifteen-month (October 2012 to December 2013) instrumental case study is set in large, healthcare organisation in England. The innovation refers to introducing a nationally recognised, inter-disciplinary dysphagia competency framework to guide workforce development about fundamental aspects of care. Adoption and adaptation will be examined at an organisational level and along two, contrasting care pathways: stroke and fractured neck of femur. A number of educational interventions will be deployed, including training a cadre of trainers to cascade the essentials of dysphagia management and developing a Dysphagia Toolkit as a learning resource. Mixed methods will be used to investigate scale-up, spread, and sustainability in acute and community settings. A purposive sample of senior managers and clinical leaders will be interviewed to identify path dependency or the context specific particularities of implementation. A pre- and post-evaluation, using mealtime observations and a survey, will investigate the learning effect on staff adherence to patient specific dysphagia recommendations and attitudes towards dysphagia, respectively. Official documents and an ethnographic field journal allow critical junctures, temporal aspects and confounding factors to be explored. DISCUSSION: Researching spread and sustainability presents methodological and practical challenges. These include fidelity, adaptation latitude, time, and organisational changes. An instrumental case study will allow these confounding factors to be tracked over time and in place. The case study is underpinned by, and will test a conceptual framework about spread, to explore theoretical generalizability.

Sustaining international partnerships: the European Master of Science Programme in Occupational Therapy, a case study.

International partnerships are a mechanism for supporting the academic development of occupational therapy and promoting cultural competence. This case study describes the factors that have helped to sustain a post-qualifying programme implemented by five higher education institutions in Denmark, the Netherlands, Sweden, Switzerland and the UK since 1999. Data collection methods were documentary analysis and the reflections of a purposive sample of six key informants. Cohort and outcome data, from 193 students from 31 countries who enrolled between 1999 and 2011, are reported. Each cohort comprises students from an average of eight countries to optimize inter-cultural dialogue. Four factors support sustainability. These are 1) supportive professional European networks; 2) timeliness and alignment with European higher education policy; 3) partnership structures and processes that emphasize joint decision making and accountability; and 4) the stimulus and satisfaction associated with internationalization. The main limitations are considering the OT-EuroMaster as an intrinsic case study and using opportunistic data collection that undermines the rigor and transferability of the findings. Future opportunities include doctoral networks, transnational research and sharing our curricula design with other Regions to spread the collaborative, capacity building endeavours more widely.

Patients' views on the impact of stroke on their roles and self: a thematic synthesis of qualitative studies.

OBJECTIVE: To synthesize patients' views on the impact of stroke on their roles and self. DATA SOURCES: PubMed, CINAHL, Embase, PsycINFO, and Cochrane searched from inception to September 2010, using a combination of relevant Medical Subject Headings and free-text terms. This search was supplemented by reference tracking. STUDY SELECTION: Qualitative studies reporting the views of people poststroke. The search yielded 494 records. Opinion articles, quantitative studies, or those reporting somatic functioning were excluded. Thirty-three studies were included. DATA EXTRACTION: Data extraction involved identifying all text presented as "results" or "findings" in the included studies, and importing this into software for the analysis of qualitative data. DATA SYNTHESIS: The abstracted text was coded and then subject to a thematic analysis and synthesis, which was discussed and agreed by the research team. Three overarching themes were identified: (1) managing discontinuity is a struggle; (2) regaining roles: to continue or adapt? and (3) context influences management of roles and self. Regaining valued roles and self was an ongoing struggle, and discontinuity and uncertainty were central to the adjustment process after stroke. CONCLUSIONS: The thematic synthesis provides new insights into the poststroke experience. Regaining or developing a new self and roles was problematic. Interventions targeted at self-management should be focused on the recognition of this problem and included in rehabilitation, to facilitate adjustment and continuity as far as possible in life poststroke.

Testing the Consolidated Framework for Implementation Research on health care innovations from South Yorkshire.

RATIONALE, AIMS AND OBJECTIVES: There is an international imperative to implement research into clinical practice to improve health care. Understanding the dynamics of change requires knowledge from theoretical and empirical studies. This paper presents a novel approach to testing a new meta theoretical framework: the Consolidated Framework for Implementation Research. METHOD: The utility of the Framework was evaluated using a post hoc, deductive analysis of 11 narrative accounts of innovation in health care services and practice from England, collected in 2010. A matrix, comprising the five domains and 39 constructs of the Framework was developed to examine the coherence of the terminology, to compare results across contexts and to identify new theoretical developments. RESULTS: The Framework captured the complexity of implementation across 11 diverse examples, offering theoretically informed, comprehensive coverage. The Framework drew attention to relevant points in individual cases together with patterns across cases; for example, all were internally developed innovations that brought direct or indirect patient advantage. In 10 cases, the change was led by clinicians. Most initiatives had been maintained for several years and there was evidence of spread in six examples. Areas for further development within the Framework include sustainability and patient/public engagement in implementation. CONCLUSION: Our analysis suggests that this conceptual framework has the potential to offer useful insights, whether as part of a situational analysis or by developing context-specific propositions for hypothesis testing. Such studies are vital now that innovation is being promoted as core business for health care.

Desperately seeking dissonance: identifying the disconfirming case in qualitative evidence synthesis.

Actively seeking the disconfirming or deviant case is properly regarded as a hallmark of trustworthiness in primary qualitative research. The need to subject emergent theory to such testing is no less important within qualitative systematic reviews. There is, as yet, little available guidance on how to implement such strategies. Few researchers have described the practicalities of seeking the disconfirming case. We survey the methodological literature to gain a better understanding of how systematic reviews of qualitative research handle the disconfirming case. We reflect on our own experience from three recent qualitative evidence syntheses. We describe how reviewers might actively manufacture opportunities to identify discrepant or refutational findings. We conclude by outlining possible methods by which a team might integrate active seeking of a disconfirming case within the overall review process.

Estimated cost of a health visitor-led protocol for perinatal mental health.

Anecdotally, protocols, care pathways and clinical guidelines are time consuming to develop and sustain, but there is little research about the actual costs of their development, use and audit.This is a notable gap considering the pervasiveness of such documents that are intended to reduce unacceptable variations in practice by standardising care processes. A case study research design was used to calculate the resource use costs of a protocol for perinatal mental health, part of the core programme for health visitors in a primary care trust in the west of England. The methods were in-depth interviews with the operational lead for the protocol (a health visitor) and documentary analysis. The total estimated cost of staff time over a five-year period (2004 to 2008) was Euro 73,598, comprising Euro 36,162 (49%) for development and Euro 37,436 (51%) for implementation. Although these are best estimates dependent upon retrospective data, they indicate the opportunity cost of staff time for a single protocol in one trust over five years. When new protocols, care pathways or clinical guidelines are proposed, the costs need to be considered and weighed against the benefits of engaging frontline staff in service improvements.

How do nurses, midwives and health visitors contribute to protocol-based care? A synthesis of the UK literature.

OBJECTIVES: To explore how nurses, midwives and health visitors contribute to the development, implementation and audit of protocol-based care. Protocol-based care refers to the use of documents that set standards for clinical care processes with the intent of reducing unacceptable variations in practice. Documents such as protocols, clinical guidelines and care pathways underpin evidence-based practice throughout the world. METHODS: An interpretative review using the five-stage systematic literature review process. The data sources were the British Nursing Index, CINAHL, EMBASE, MEDLINE and Web of Science from onset to 2005. The Journal of Integrated Care Pathways was hand searched (1997-June 2006). Thirty three studies about protocol-based care in the United Kingdom were appraised using the Qualitative Assessment and Review Instrument (QARI version 2). The literature was synthesized inductively and deductively, using an official 12-step guide for development as a framework for the deductive synthesis. RESULTS: Most papers were descriptive, offering practitioner knowledge and positive findings about a locally developed and owned protocol-based care. The majority were instigated in response to clinical need or service re-design. Development of protocol-based care was a non-linear, idiosyncratic process, with steps omitted, repeated or completed in a different order. The context and the multiple purposes of protocol-based care influenced the development process. Implementation and sustainability were rarely mentioned, or theorised as a change. The roles and activities of nurses were so understated as to be almost invisible. There were notable gaps in the literature about the resource use costs, the engagement of patients in the decision-making process, leadership and the impact of formalisation and new roles on inter-professional relations. CONCLUSIONS: Documents that standardise clinical care are part of the history of nursing as well as contemporary evidence-based care and expanded roles. Considering the proliferation and contested nature of protocol-based care, the dearth of literature about the contribution, experience and outcomes for nurses, midwives and health visitors is noteworthy and requires further investigation.

An implementation research agenda.

In October 2006, the Chief Medical Officer (CMO) of England asked Professor Sir John Tooke to chair a High Level Group on Clinical Effectiveness in response to the chapter 'Waste not, want not' in the CMOs 2005 annual report 'On the State of the Public Health'. The high level group made recommendations to the CMO to address possible ways forward to improve clinical effectiveness in the UK National Health Service (NHS) and promote clinical engagement to deliver this. The report contained a short section on research needs that emerged from the process of writing the report, but in order to more fully identify the relevant research agenda Professor Sir John Tooke asked Professor Martin Eccles to convene an expert group - the Clinical Effectiveness Research Agenda Group (CERAG) - to define the research agenda. The CERAG's terms of reference were 'to further elaborate the research agenda in relation to pursuing clinically effective practice within the (UK) National Health Service'. This editorial presents the summary of the CERAG report and recommendations.

What is protocol-based care? A concept analysis.

AIM: To define protocol-based care to make this way of delivering health care amenable to theoretical and empirical studies. BACKGROUND: Although protocol-based care is associated with the evidence-based practice and standardization movements, it is an ill-defined and understood concept. METHOD: A multiphase concept analysis, inspired by an evolutionary view was used to clarify 'what is protocol-based care'. The inductive, five-phase process drew upon content analysis of policy documents and the literature, plus interviews with a purposive sample of 35 opinion leaders. RESULTS: The term was used interchangeably with protocols, pathways and guidelines in policy and guidance documents. A search of seven databases produced only 57 references to protocol-based care. The concept analysis revealed a continuum of scope and specificity and also distinguished specialist and generic applications of protocol-based care. CONCLUSIONS: Managers need to take cognizance of the significance and complexity of protocol-based care when introducing this way of working.

Challenges and strategic solutions for a research emergent profession.

This paper explores some of the truisms associated with evidence-based practice. The intention is to remind the reader that evidence-based practice is a decision-making tool and not a rule; and to propose a strategic approach to overcoming the challenges we face as a research emergent profession.