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Objectives: The challenges of improving the integration of care for older people with complex care needs are well recognised. Evidence suggests that solutions should be co-designed with older people to ensure they are contextually relevant and person-centred. Methods: As a first step in a co-design project to improve integrated care for older people, seven interviews and three workshops were held with older people and service providers. Data collected via recordings, notes and journey maps were inductively analysed. Results: Five themes were identified: relationships and roles, patient capacity and safety, information and systems, multiway communication, and transitions and flow. This created a more holistic and person-centred picture of integrated care than typically derived from published literature. Conclusions: Older people perceive integrated care from relational, organisational, informational and individual viewpoints. This reinforces the central importance of adopting a person-centred, as opposed to health system-focused, approach to designing and implementing integrated care solutions Refereed/Peer-reviewed

Background Multi-faceted approaches are generally recognised as the most effective way to support the implementation of evidence into practice. Audit and feedback often constitute one element of a multi-faceted implementation package, alongside other strategies, such as interactive education and facilitated support mechanisms. This paper describes a multi-faceted implementation strategy that used the Joanna Briggs Institute Practical Application of Clinical Evidence System (PACES) as an online audit tool to support facilitators working to introduce evidence-based continence recommendations in nursing homes in four different European countries. Aims/objectives The paper describes the experience of using PACES with an international group of nursing home facilitators. In particular, the objectives of the paper are: to describe the process of introducing PACES to internal facilitators in eight nursing homes; to discuss the progress made during a 12-month period of collecting and analysing audit data using PACES; to summarise the collective experience of using PACES, including reflections on its strengths and limitations. Methods Descriptive data were collected during the 12-month period of working with PACES in the eight nursing home sites. These data included digital and written notes taken at an initial 3-day introductory programme, at monthly teleconferences held between the external and internal facilitators and at a final 2-day meeting. Qualitative analysis of the data was undertaken on an ongoing basis throughout the implementation period, which enabled formative evaluation of PACES. A final summative evaluation of the experience of using PACES was undertaken as part of the closing project meeting in June 2011. Results The nursing home facilitators took longer than anticipated to introduce PACES and it was only after 9‐10 months that they became confident and comfortable using the system. This was due to a combination of factors, including a lack of audit knowledge and skills, limited IT access and skills, language difficulties and problems with the PACES system itself. The initial plan of undertaking a full baseline audit followed by focused action cycles had to be revised to allow a more staged, smaller-scale approach to implementation and audit. This involved simplifying the audit process and removing steps such as the calculation of population size estimates. As a result, an accurate baseline measure, prior to introducing changes to continence care, was not achieved. However, by the end of the 12 months, the majority of facilitators had undertaken a full audit and reported value in the process. In particular, they benefited from comparing audit data across sites to share learning and best practice. Discussion/conclusion Working with PACES as part of a facilitated programme to support the implementation of evidence-based continence recommendations in nursing homes in four European countries has been a valuable learning experience, although not without its challenges. The findings highlight the importance of thorough training and support for first time users of PACES and the need to make the audit process as simple as possible in the initial stages.

Aims. This paper reports a literature review exploring the relationship between quality of care and selected organizational variables through a consideration of what is meant by perceptions of quality, whose perceptions are accorded prominence, and whether changes in staffing, skill mix and autonomy affect perceptions of quality. Background. Three basic ideas underpin this literature review: the growing focus on quality improvement in health care, concerns about the quality of care, and the move towards patient involvement and consultation. Of particular interest is the way in which changes in nurse staffing, skill mix and autonomy may affect the delivery of quality patient care. Methods. A search was conducted using the CINAHL, Medline and Embase databases. Key words used were quality of health care; quality of nursing care; nurse; patient; skill mix; nurse–patient ratio; outcomes; adverse health care events and autonomy. The objective was to draw together a diverse collection of literature related to the field of health care quality. Papers were included for their relevance to the field of enquiry. The original search was conducted in 2003 and updated in 2004. Findings. Quality of care is a complex, multi-dimensional concept which presents researchers with a challenge when attempting to evaluate it. Traditional nursing assessment tools have fallen out of use, partly because they have failed to provide opportunities to engage with and access the views of patients or nurses. There is also evidence that patient satisfaction as an indicator of quality is compromised on a number of fronts. There is conflicting information on how nurses and patients think about quality. Research looking at the relationship between the selected organizational variables and perceptions of quality also suffers from a number of limitations. We argue that there is a requirement for more patient-centred research exploring perceptions of quality and differences in nurse staffing, skill mix and autonomy.

The challenges of implementing evidence-based practice are complex and varied. Against this background a framework has been developed to represent the multiple factors that may influence the implementation of evidence into practice. It is proposed that successful implementation is dependent upon the nature of the evidence being used, the quality of context, and, the type of facilitation required to enable the change process. This study sets out to scrutinize the elements of the framework through empirical enquiry.The aim of the study was to address the following questions: * What factors do practitioners identify as the most important in enabling implementation of evidence into practice? * What are the factors practitioners identify that mediate the implementation of evidence into practice? * Do the concepts of evidence, context and facilitation constitute the key elements of a framework for getting evidence into practice?The study was conducted in two phases. Phase 1: Exploratory focus groups (n = 2) were conducted to inform the development of an interview guide. This was used with individual key informants in case study sites. Phase 2: Two sites with on-going or recent implementation projects were studied. Within sites semi-structured interviews were conducted (n = 17).A number of key issues in relation to the implementation of evidence into practice emerged including: the nature and role of evidence, relevance and fit with organizational and practice issues, multi-professional relationships and collaboration, role of the project lead and resources.The results are discussed with reference to the wider literature and in relation to the on-going development of the framework. Crucially the growing body of evidence reveals that a focus on individual approaches to implementing evidence-based practice, such as skilling-up practitioners to appraise research evidence, will be ineffective by themselves.Key elements that require attention in implementing evidence into practice are presented and may provide a useful checklist for future implementation and evaluation projects.

Background. Considerable financial and philosophical effort has been expended on the evidence-based practice agenda. Whilst few would disagree with the notion of delivering care based on information about what works, there remain significant challenges about what evidence is, and thus how practitioners use it in decision-making in the reality of clinical practice. Aim. This paper continues the debate about the nature of evidence and argues for the use of a broader evidence base in the implementation of patient-centred care. Discussion. Against a background of financial constraints, risk reduction, increased managerialism research evidence, and more specifically research about effectiveness, have assumed pre-eminence. However, the practice of effective nursing, which is mediated through the contact and relationship between individual practitioner and patient, can only be achieved by using several sources of evidence. This paper outlines the potential contribution of four types of evidence in the delivery of care, namely research, clinical experience, patient experience and information from the local context. Fundamentally, drawing on these four sources of evidence will require the bringing together of two approaches to care: the external, scientific and the internal, intuitive. Conclusion. Having described the characteristics of a broader evidence base for practice, the challenge remains to ensure that each is as robust as possible, and that they are melded coherently and sensibly in the real time of practice. Some of the ideas presented in this paper challenge more traditional approaches to evidence-based practice. The delivery of effective, evidence-based patient-centred care will only be realized when a broader definition of what counts as evidence is embraced.

Getting evidence into practice: the role and function of facilitation Aim of paper. This paper presents the findings of a concept analysis of facilitation in relation to successful implementation of evidence into practice. Background. In 1998, we presented a conceptual framework that represented the interplay and interdependence of the many factors influencing the uptake of evidence into practice. One of the three elements of the framework was facilitation, alongside the nature of evidence and context. It was proposed that facilitators had a key role in helping individuals and teams understand what they needed to change and how they needed to change it. As part of the on-going development and refinement of the framework, the elements within it have undergone a concept analysis in order to provide theoretical and conceptual clarity. Methods. The concept analysis approach was used as a framework to review critically the research literature and seminal texts in order to establish the conceptual clarity and maturity of facilitation in relation to its role in the implementation of evidence-based practice. Findings. The concept of facilitation is partially developed and in need of delineation and comparison. Here, the purpose, role and skills and attributes of facilitators are explored in order to try and make distinctions between this role and other change agent roles such as educational outreach workers, academic detailers and opinion leaders. Conclusions. We propose that facilitation can be represented as a set of continua, with the purpose of facilitation ranging from a discrete task-focused activity to a more holistic process of enabling individuals, teams and organizations to change. A number of defining characteristics of facilitation are proposed. However, further research to clarify and evaluate different models of facilitation is required.

Quality, audit and standard setting are major issues on the present day nursing and health care agenda. Considerable time, energy and resources have been invested in developing and implementing a range of different quality and audit systems, yet there is limited evidence to date to suggest that they are having any significant impact in terms of changing practice and improving patient care. This paper will present the results of a study undertaken to evaluate the implementation of three of the most common nursing quality systems used in the United Kingdom: Monitor, Qualpacs and the dynamic standard setting system (DySSSy). In each case, the focus was on identifying key factors in the process of implementation that could predict positive programme outcomes--defined in terms of acceptance by clinical nursing staff and perceived impact on the quality of patient care. The study adopted a three-stage evaluation design, with three distinct levels of investigation and analysis, and utilized a range of descriptive and exploratory methods. In total, 14 sites implementing one of the three nursing quality systems were studied. Additional data, derived from individuals' experiences of implementing quality in nursing, were used to enhance and validate the findings. The results indicated a number of important system-related, contextual and practical issues of implementation. These were underpinned by two key factors, defined as ownership for quality and action to improve. However, most present day nursing quality programmes appear to be failing to embrace these two concepts simultaneously. The paper will conclude by discussing the implications of these findings for future developments in nursing and health care quality improvement.