Patient, family member and caregiver engagement in shaping policy for primary health care teams in three Canadian Provinces.

INTRODUCTION: Improving health services integration through primary health care (PHC) teams for patients with chronic conditions is essential to address their complex health needs and facilitate better health outcomes. The objective of this study was to explore if and how patients, family members, and caregivers were engaged or wanted to be engaged in developing, implementing and evaluating health policies related to PHC teams. This patient-oriented research was carried out in three provinces across Canada: British Columbia, Alberta and Ontario. METHODS: A total of 29 semi-structured interviews with patients were conducted across the three provinces and data were analysed using thematic analysis. RESULTS: Three key themes were identified: motivation for policy engagement, experiences with policy engagement and barriers to engagement in policy. The majority of participants in the study wanted to be engaged in policy processes and advocate for integrated care through PHC teams. Barriers to patient engagement in policy, such as lack of opportunities for engagement, power imbalances, tokenism, lack of accessibility of engagement opportunities and experiences of racism and discrimination were also identified. CONCLUSION: This study increases the understanding of patient, family member, and caregiver engagement in policy related to PHC team integration and the barriers that currently exist in this engagement process. This information can be used to guide decision-makers on how to improve the delivery of integrated health services through PHC teams and enhance patient, family member, and caregiver engagement in PHC policy. PATIENT OR PUBLIC CONTRIBUTION: We would like to acknowledge the contributions of our patient partners, Brenda Jagroop and Judy Birdsell, who assisted with developing and pilot testing the interview guide. Judy Birdsell also assisted with the preparation of this manuscript. This study also engaged patients, family members, and caregivers to share their experiences with engagement in PHC policy.

An implementation history of primary health care transformation: Alberta's primary care networks and the people, time and culture of change.

BACKGROUND: Primary care, and its transformation into Primary Health Care (PHC), has become an area of intense policy interest around the world. As part of this trend Alberta, Canada, has implemented Primary Care Networks (PCNs). These are decentralized organizations, mandated with supporting the delivery of PHC, funded through capitation, and operating as partnerships between the province's healthcare administration system and family physicians. This paper provides an implementation history of the PCNs, giving a detailed account of how people, time, and culture have interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment. METHODS: Our implementation history is built out of an analysis of policy documents and qualitative interviews. We conducted an interpretive analysis of relevant policy documents (n = 20) published since the first PCN was established. We then grounded 12 semi-structured interviews in that initial policy analysis. These interviews explored 11 key stakeholders' perceptions of PHC transformation in Alberta generally, and the formation and evolution of the PCNs specifically. The data from the policy review and the interviews were coded inductively, with participants checking our emerging analyses. RESULTS: Over time, the PCNs have shifted from an initial Frontier Era that emphasized local solutions to local problems and featured few rules, to a present Era of Accountability that features central demands for standardized measures, governance, and co-planning with other elements of the health system. Across both eras, the PCNs have been first and foremost instruments and supporters of family physician authority and autonomy. A core group of people emerged to create the PCNs and, over time, to develop a long-term Quality Improvement (QI) vision and governance plan for them as organizations. The continuing willingness of both these groups to work at understanding and aligning one another's cultures to achieve the transformation towards PHC has been central to the PCNs' survival and success. CONCLUSIONS: Generalizable lessons from the implementation history of this emerging policy experiment include: The need for flexibility within a broad commitment to improving quality. The importance of time for individuals and organizations to learn about: quality improvement; one another's cultures; and how best to support the transformation of a system while delivering care locally.

Insights into the impact and use of research results in a residential long-term care facility: a case study.

BACKGROUND: Engaging end-users of research in the process of disseminating findings may increase the relevance of findings and their impact for users. We report findings from a case study that explored how involvement with the Translating Research in Elder Care (TREC) study influenced management and staff at one of 36 TREC facilities. We conducted the study at 'Restwood' (pseudonym) nursing home because the Director of Care engaged actively in the study and TREC data showed that this site differed on some areas from other nursing homes in the province. The aims of the case study were two-fold: to gain a better understanding of how frontline staff engage with the research process, and to gain a better understanding of how to share more detailed research results with management. METHODS: We developed an Expanded Feedback Report for use during this study. In it, we presented survey results that compared Restwood to the best performing site on all variables and participating sites in the province. Data were collected regarding the Expanded Feedback Report through interviews with management. Data from staff were collected through interviews and observation. We used content analysis to derive themes to describe key aspects related to the study aims. RESULTS: We observed the importance of understanding organizational routines and the impact of key events in the facility's environment. We gleaned additional information that validated findings from prior feedback mechanisms within TREC. Another predominant theme was the sense that the opportunity to engage in a research process was reaffirming for staff (particularly healthcare aides)-what they did and said mattered, and TREC provided a means of having one's voice heard. We gained valuable insight from the Director of Care about how to structure and format more detailed findings to assist with interpretation and use of results. CONCLUSIONS: Four themes emerged regarding staff engagement with the research process: sharing feedback reports from the TREC study; the meaning of TREC to staff; understanding organizational context; and using the study feedback for improvement at Restwood. This study has lessons for researchers on how to share research results with study participants, including management.

Development and assessment of the Alberta Context Tool.

BACKGROUND: The context of healthcare organizations such as hospitals is increasingly accepted as having the potential to influence the use of new knowledge. However, the mechanisms by which the organizational context influences evidence-based practices are not well understood. Current measures of organizational context lack a theory-informed approach, lack construct clarity and generally have modest psychometric properties. This paper presents the development and initial psychometric validation of the Alberta Context Tool (ACT), an eight dimension measure of organizational context for healthcare settings. METHODS: Three principles guided the development of the ACT: substantive theory, brevity, and modifiability. The Promoting Action on Research Implementation in Health Services (PARiHS) framework and related literature were used to guide selection of items in the ACT. The ACT was required to be brief enough to be tolerated in busy and resource stretched work settings and to assess concepts of organizational context that were potentially modifiable. The English version of the ACT was completed by 764 nurses (752 valid responses) working in seven Canadian pediatric care hospitals as part of its initial validation. Cronbach's alpha, exploratory factor analysis, analysis of variance, and tests of association were used to assess instrument reliability and validity. RESULTS: Factor analysis indicated a 13-factor solution (accounting for 59.26% of the variance in 'organizational context'). The composition of the factors was similar to those originally conceptualized. Cronbach's alpha for the 13 factors ranged from .54 to .91 with 4 factors performing below the commonly accepted alpha cut off of .70. Bivariate associations between instrumental research utilization levels (which the ACT was developed to predict) and the ACT's 13 factors were statistically significant at the 5% level for 12 of the 13 factors. Each factor also showed a trend of increasing mean score ranging from the lowest level to the highest level of instrumental research use, indicating construct validity. CONCLUSIONS: To date, no completely satisfactory measures of organizational context are available for use in healthcare. The ACT assesses several core domains to provide a comprehensive account of organizational context in healthcare settings. The tool's strengths are its brevity (allowing it to be completed in busy healthcare settings) and its focus on dimensions of organizational context that are modifiable. Refinements of the instrument for acute, long term care, and home care settings are ongoing.

Translating research in elder care: an introduction to a study protocol series.

BACKGROUND: The knowledge translation field is undermined by two interrelated gaps - underdevelopment of the science and limited use of research in health services and health systems decision making. The importance of context in theory development and successful translation of knowledge has been identified in past research. Additionally, examination of knowledge translation in the long-term care (LTC) sector has been seriously neglected, despite the fact that aging is increasingly identified as a priority area in health and health services research. AIMS: The aims of this study are: to build knowledge translation theory about the role of organizational context in influencing knowledge use in LTC settings and among regulated and unregulated caregivers, to pilot knowledge translation interventions, and to contribute to enhanced use of new knowledge in LTC. DESIGN: This is a multi-level and longitudinal program of research comprising two main interrelated projects and a series of pilot studies. An integrated mixed method design will be used, including sequential and simultaneous phases to enable the projects to complement and inform one another. Inferences drawn from the quantitative and qualitative analyses will be merged to create meta-inferences. OUTCOMES: Outcomes will include contributions to (knowledge translation) theory development, progress toward resolution of major conceptual issues in the field, progress toward resolution of methodological problems in the field, and advances in the design of effective knowledge translation strategies. Importantly, a better understanding of the contextual influences on knowledge use in LTC will contribute to improving outcomes for residents and providers in LTC settings.

Health researchers in Alberta: an exploratory comparison of defining characteristics and knowledge translation activities.

BACKGROUND: Canadian funding agencies are no longer content to support research that solely advances scientific knowledge, and key directives are now in place to promote research transfer to policy- and decision-makers. Therefore, it is necessary to improve our understanding of how researchers are trained and supported to facilitate knowledge translation activities. In this study, we investigated differences in health researcher characteristics and knowledge translation activities. METHODS: Our sample consisted of 240 health researchers from three Alberta universities. Respondents were classified by research domain [basic (n = 72) or applied (n = 168)] and faculty [medical school (n = 128) or other health science (n = 112)]. We examined our findings using Mode I and Mode II archetypes of knowledge production, which allowed us to consider the scholarly and social contexts of knowledge production and translation. RESULTS: Differences among health researcher professional characteristics were not statistically significant. There was a significant gender difference in the applied researcher faculty group, which was predominantly female (p < .05). Research domain was linked to translation activities. Applied researchers reported engaging in significantly more Mode II activities than basic researchers (p < .001), and scored higher than basic researchers regarding the perceived importance of translation activities (Mode I, p = .01; Mode II, p < .001). Main effects of faculty were limited to engaged dissemination (medical school < other faculties; p = .025) and number of publications (medical school > other faculties; p = .004). There was an interaction effect for research domain and faculty group for number of publications (p = .01), in that applied researchers in medical faculties published more than their peers in other faculty groups. CONCLUSION: Our findings illustrate important differences between health researchers and provide beginning insights into their professional characteristics and engagement in Mode I and Mode II activities. A future study designed to examine these dimensions in greater detail, including potential covariates across more varied institutions, would yield richer insights and enable an examination of relative influences, needs and costs of each mode of activity.