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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

PurposeThe study describes the implementation of a novel strategy, entitled the Action Learning Set Facilitation Model, to develop internal facilitation capability to lead change. The Model incorporated the Novice-Experienced-Expert pathway, a facilitation development approach underpinning the integrated-Promoting Action on Research Implementation in Health Services Implementation Framework, with action learning methodology.Design/methodology/approachA mixed-methods descriptive approach reports the results of 22 interviews, 182 Action Learning Sets and 159 post program survey data sets to explore facilitator experiences, strengths and potential application of the Model.FindingsAt program completion, five novice (of 174) and one experienced (of 27) facilitator transitioned to the next facilitation level. The three groups of facilitators described positive change in confidence and facilitation skill, and experience of action learning sets. Inconsistencies between self-report competence and observed practice amongst novices was reported. Novices had decreasing exposure to the Model due to factors related to ongoing organisational change. Internal facilitators were considered trusted and credible facilitators.Research limitations/implicationsThere are practical and resource implications in investing in internal facilitation capability, noting proposed and real benefits of similar development programs may be compromised during, or as a consequence of organisational change. Further research describing application of the facilitation model, strategies to enhance multisystemic support for programs and evaluation support are suggested.Practical implicationsThe Action Learning Set Facilitation Model offers promise in developing internal facilitation capability supporting change in organisations. Critical success factors include building broad scale internal capability, stable leadership and longitudinal support to embed practice.Originality/valueThis is the first application of the facilitation component of the integrated-Promoting Action on Research Implementation in Health Services implementation framework embedded to action learning sets as an implementation science strategy for leader development supporting organisational change.

Background An intervention ‘Better Oral Health in Home Care’ was introduced (2012–2014) to improve the oral health of older people receiving community aged care services. Implementation of the intervention was theoretically framed by the Promoting Action on Research Implementation in Health Services framework. Process outcomes demonstrated significant improvements in older people’s oral health. Objective To evaluate the extent to which the intervention has been embedded and sustained into routine community aged care practice 3 years after the initial implementation project. Design A Realist Evaluation applying Normalisation Process Theory within a single case study setting. Setting Community aged care (home care) provider in South Australia, Australia. Participants Purposeful sampling was undertaken. Twelve staff members were recruited from corporate, management and direct care positions. Two consumers representing high and low care recipients also participated. Methods Qualitative methods were applied in two subcases, reflecting different contextual settings. Data were collected via semi-structured interviews and analysed deductively by applying the Normalisation Process Theory core constructs (with the recommended phases of the Realist Evaluation cycle). Retrospective and prospective analytic methods investigated how the intervention has been operationalised by comparing two timeframes: Time 1 (Implementation June 2012–December 2014) and Time 2 (Post-implementation July 2017–July 2018). Results At Time 1, the initial program theory proposed that multi-level facilitation contributed to a favourable context that triggered positive mechanisms supportive of building organisational and workforce oral healthcare capacity. At Time 2, an alternative program theory of how the intervention has unfolded in practice described a changed context following the withdrawal of the project facilitation processes with the triggering of alternative mechanisms that have made it difficult for staff to embed sustainable practice. Conclusion Findings concur with the literature that successful implementation outcomes do not necessarily guarantee sustainability. The study has provided a deeper explanation of how contextual characteristics have contributed to the conceptualisation of oral healthcare as a low priority, basic work-ready personal care task and how this, in turn, hindered the embedding of sustainable oral healthcare into routine community aged care practice. This understanding can be used to better inform the development of strategies, such as multi-level facilitation, needed to navigate contextual barriers so that sustainable practice can be achieved.

Background: The approach and style of leaders is known to be an important factor influencing the translation of research evidence into nursing practice. However, questions remain as to what types of roles are most effective and the specific mechanisms through which influence is achieved.Objectives: The aim of the study was to enhance understanding of the mechanisms by which key nursing roles lead the implementation of evidence-based practice across different care settings and countries and the contextual factors that influence them.Design: The study employed a qualitative descriptive approach.Settings: Data collection was undertaken in acute care and primary/community health care settings in Australia, Canada, England and Sweden.Participants: 55 individuals representing different levels of the nursing leadership structure (executive to frontline), roles (managers and facilitators), sectors (acute and primary/community) and countries.Methods: Individual semi-structured interviews were conducted with all participants exploring their roles and experiences of leading evidence-based practice. Data were analysed through a process of qualitative content analysis.Results: Different countries had varying structural arrangements and roles to support evidence-based nursing practice. At a cross-country level, three main themes were identified relating to different mechanisms for enacting evidence-based practice, contextual influences at a policy, organisational and service delivery level and challenges of leading evidence-based practice.Conclusions: National policies around quality and performance shape priorities for evidence-based practice, which in turn influences the roles and mechanisms for implementation that are given prominence. There is a need to maintain a balance between the mechanisms of managing and monitoring performance and facilitating critical questioning and reflection in and on practice. This requires a careful blending of managerial and facilitative leadership. The findings have implications for theory, practice, education and research relating to implementation and evidence-based practice.

IMPORTANCE: Hospital-associated complications of older people (HAC-OPs) include delirium, hospital-associated disability, incontinence, pressure injuries, and falls. These complications may be preventable by age-friendly principles of care, including early mobility, good nutrition and hydration, and meaningful cognitive engagement; however, implementation is challenging. OBJECTIVES: To implement and evaluate a ward-based improvement program (“Eat Walk Engage”) to more consistently deliver age-friendly principles of care to older individuals in acute inpatient wards. DESIGN, SETTING, AND PARTICIPANTS: This cluster randomized CHERISH (Collaboration for Hospitalised Elders Reducing the Impact of Stays in Hospital) trial enrolled 539 consecutive inpatients aged 65 years or older, admitted for 3 days or more to study wards, from October 2, 2016, to April 3, 2017, with a 6-month follow-up. The study wards comprised 8 acute medical and surgical wards in 4 Australian public hospitals. Randomization was stratified by hospital, providing 4 clusters in intervention and in control groups. Statistical analysis was performed from August 28, 2018, to October 17, 2021, on an intention-to-treat basis. INTERVENTION: A trained facilitator supported a multidisciplinary work group on each intervention ward to improve the care practices, environment, and culture to support key age-friendly principles. MAIN OUTCOMES AND MEASURES: Primary outcomes were incidence of any HAC-OP and length of stay. Secondary outcomes were incidence of individual HAC-OPs, facility discharge, 6-month mortality, and all-cause readmission. Outcomes were analyzed at the individual level, adjusted for confounders and clustering. RESULTS: A total of 265 participants on 4 intervention wards (124 women [46.8%]; mean [SD] age, 75.9 [7.3] years) and 274 participants on 4 control wards (145 women [52.9%]; mean [SD] age, 78.0 [8.2] years) were enrolled. The composite primary outcome of any HAC-OP occurred for 115 of 248 intervention participants (46.4%) and 129 of 249 control participants (51.8%) (intervention group: adjusted odds ratio, 1.07; 95% CI, 0.71-1.61). The median length of stay was 6 days (IQR, 4-9 days) for the intervention group and 7 days (IQR, 5-10 days) for the control group (adjusted hazard ratio, 0.96; 95% credible interval, 0.80-1.15). The incidence of delirium was significantly lower for intervention participants (adjusted odds ratio, 0.53; 95% CI, 0.31-0.90). There were no significant differences in other individual HAC-OPs, facility discharge, mortality, or readmissions. CONCLUSIONS AND RELEVANCE: The Eat Walk Engage program did not reduce the composite primary outcome of any HAC-OP or length of stay, but there was a significant reduction in the incidence of delirium. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12615000879561

ObjectiveTo identify factors that influence procurement and disinvestment decisions for wound care products in the acute care setting. MethodsA qualitative descriptive study was undertaken. Eighteen face-to-face semi-structured interviews were conducted with purposively sampled senior clinical and non-clinical managers from three Australian acute care hospitals with responsibility for consumables procurement and disinvestment decisions. Data were coded and analysed thematically. ResultsThree main themes (Systems and triggers, Evidence-free zone, Getting the governance right) with sub-themes were identified that reflect that: (1) procurement processes were often ad hoc and workarounds common. Disinvestment was poorly understood and opportunities were missed to reduce use of low value products ; (2) product selection was commonly based on clinician preference, contractual obligations and information from industry representatives; and (3) improved evidence-based governance and processes are needed to connect procurement and disinvestment decisions and to minimise the influences of clinician preference and industry representatives on product selection. ConclusionsSystematic and evidence-based approaches are needed to strengthen procurement and disinvestment decisions related to consumables such as wound care products and to minimise the purchasing of low-value products Decision-making frameworks should consider cost and clinical effectiveness and enable the identification of opportunities to disinvest from low-value products. What is known about the topic?High volume–low unit cost healthcare consumables such as wound care products are a major component of healthcare expenditure. Disinvestment from low-value wound care products has potential to improve patient outcomes and optimise health resources. What does this paper add?Disinvestment was poorly understood and considered in isolation from procurement decisions. Procurement decisions were rarely informed by research evidence, with clinicians exercising considerable freedom to make purchasing decisions based on product preference and industry information. Frameworks and guidelines are needed to guide procurement and disinvestment decision-making for wound care products. What are the implications for practitioners?New models for procurement and disinvestment decision-making for wound care products could help to strengthen decision-making processes, facilitate evidence-based product choices and also prompt consideration of removal of low-value products.

This paper considers an implication of the idea that proposals for integrated care for older people should start from a focus on the patient, consider co-production solutions to the problems of care fragmentation, and be at a system-wide, cross-organisational level. It follows that the analysis, design and therefore evaluation of integrated care projects should be based upon the journeys which older patients with multiple chronic conditions usually have to make from professional to professional and service to service. A systematic realistic review of recent research on integrated care projects identified a number of key mechanisms for care integration, including multidisciplinary care teams, care planning, suitable IT support and changes to organisational culture, besides other activities and contexts which assist care 'integration.' Those findings suggest that bringing the diverse services that older people with multiple chronic conditions need into a single organisation would remove many of the inter-organisational boundaries that impede care 'integration' and make it easier to address the interprofessional and inter-service boundaries.

Background A multitude of theories, models and frameworks relating to implementing evidence-based practice in health care exist, which can be overwhelming for clinicians and clinical researchers new to the field of implementation science. Clinicians often bear responsibility for implementation, but may be unfamiliar with theoretical approaches designed to inform or understand implementation. Main text In this article, a multidisciplinary group of clinicians and health service researchers present a pragmatic guide to help clinicians and clinical researchers understand what implementation theories, models and frameworks are; how a theoretical approach to implementation might be used; and some prompts to consider when selecting a theoretical approach for an implementation project. Ten commonly used and highly cited theoretical approaches are presented, none of which have been utilised to their full potential in the literature to date. Specifically, theoretical approaches tend to be applied retrospectively to evaluate or interpret findings from a completed implementation project, rather than being used to plan and design theory-informed implementation strategies which would intuitively have a greater likelihood of success. We emphasise that there is no right or wrong way of selecting a theoretical approach, but encourage clinicians to carefully consider the project’s purpose, scope and available data and resources to allow them to select an approach that is most likely to “value-add” to the implementation project. Conclusion By assisting clinicians and clinical researchers to become confident in selecting and applying theoretical approaches to implementation, we anticipate an increase in theory-informed implementation projects. This then will contribute to more nuanced advice on how to address evidence-practice gaps and ultimately to contribute to better health outcomes. Electronic supplementary material The online version of this article (10.1186/s12913-018-3671-z) contains supplementary material, which is available to authorized users.

Background: The 'Facilitating Implementation of Research Evidence' study found no significant differences between sites that received two types of facilitation support and those that did not on the primary outcome of documented compliance with guideline recommendations. Process evaluation highlighted factors that influenced local, internal facilitators' ability to enact the roles as envisaged. In this paper, the external facilitators responsible for designing and delivering the two types of facilitation intervention analyse why the interventions proved difficult to implement as expected, including the challenge of balancing fidelity and adaptation.Methods: Qualitative data sources included notes from monthly internal-external facilitator teleconference meetings, from closing events for the two facilitation interventions and summary data analyses from repeated interviews with 16 internal facilitators. Deductive and inductive data analysis was led by an independent researcher to evaluate how facilitation in practice compared to the logic pathways designed to guide fidelity in the delivery of the interventions.Results: The planned facilitation interventions did not work as predicted. Difficulties were encountered in each of the five elements of the logic pathway: recruitment and selection of appropriate internal facilitators, preparation for the role, ability to apply facilitation knowledge and skills at a local level, support and mentorship from external facilitators via monthly teleconferences, working collaboratively and enabling colleagues to implement guideline recommendations. Moreover, problems were cumulative and created tensions for the external facilitators in terms of balancing the logic pathway with a more real-world, flexible and iterative approach to facilitation.Conclusion: Evaluating an intervention that is fluid and dynamic within the methodology of a randomised controlled trial is complex and challenging. At a practical level, relational aspects of facilitation are critically important. It is essential to recruit and retain individuals with the appropriate set of skills and characteristics, explicit support from managerial leaders and accessible mentorship from more experienced facilitators. At a methodological level, there is a need for attention to the balance between fidelity and adaptation of interventions. For future studies, we suggest a theoretical approach to fidelity, with a focus on mechanisms, informed by prospective use of process evaluation data and more detailed investigation of the context-facilitation dynamic.

Background: The Carer Support Needs Assessment Tool (CSNAT) intervention is an evidence-based, person-centred approach to carer assessment and support within palliative care. As such, it requires a change in practice from a practitioner- to a carer-led assessment and support process. A paucity of studies have investigated factors affecting implementation of evidence based interventions within palliative care. Objectives: To examine differences between high and low adopters of the CSNAT intervention in terms of practitioner attitudes to the intervention and organisational context.Methods: Phase IV study of implementation of the CSNAT intervention at scale in 36 UK palliative care services over six months. Survey at baseline and six months of practitioners at implementation sites, informed by the Promoting Action on Research Implementation in Health Services (PARIHS) Framework. Survey tools: (i) questionnaire to assess attitudes to the CSNAT intervention; (ii) Alberta Context Tool (ACT) to assess organisational context. Monthly data on intervention use enabled service classification as ‘high’ or ‘low’ adopters. Results: 157/462 surveys returned at baseline; 69/462 at six months. Compared with ‘low’ adoption services, ‘high’ adopters were more likely to be hospice at home and day services; have a higher ratio of internal facilitators to total staff numbers; and higher scores for ACT ‘informal interactions’ denoting more discussions about care between colleagues. Both had similarly positive attitudes to the CSNAT intervention pre-implementation, but by six months ‘low’ adoption services developed significantly more negative attitudes; while in ‘high’ adoption services attitudes mostly remained the same/improved.Linking evidence to action: Implementation may be more successful for services that offer regular opportunities to use the intervention in practice, have sufficient levels of facilitators, stimulate more staff discussion, and encourage maintenance of positive motivation. Implementation of person-centred interventions needs to plan for such factors. This has informed an implementation toolkit for the CSNAT intervention.

Background: \ud \ud Accelerating the implementation of new technology in healthcare is typically complex and multi-faceted. One strategy is to charge a national agency with the responsibility for facilitating implementation. This study examines the role of such an agency in the English National Health Service. In particular, it compares two different facilitation strategies employed by the agency to support the implementation of insulin pump therapy.\ud \ud Methods: \ud \ud The research involved an empirical case study of four healthcare organisations receiving different levels of facilitation from the national agency: two received active hands-on facilitation; one was the intended recipient of a more passive, web-based facilitation strategy; the other implemented the technology without any external facilitation. The primary method of data collection was semi structured qualitative interviews with key individuals involved in implementation. The integrated-PARIHS framework was applied as a conceptual lens to analyse the data.\ud \ud Results: \ud \ud The two sites that received active facilitation from an Implementation Manager in the national agency made positive progress in implementing the technology. In both sites there was a high level of initial receptiveness to implementation. This was similar to a site that had successfully introduced insulin pump therapy without facilitation support from the national agency. By contrast, a site that did not have direct contact with the national agency made\ud little progress with implementation, despite the availability of a web-based implementation resource. Clinicians expressed differences of opinion around the value and effectiveness of the technology and contextual barriers related to funding for implementation persisted. The national agency’s intended roll out strategy using passive web-based facilitation appeared to have little impact.\ud \ud Conclusions: \ud \ud When favourable conditions exist, in terms of agreement around the value of the technology, clinician receptiveness and motivation to change, active facilitation via an external agency can help to structure the implementation process and address contextual barriers. Passive facilitation using web-based implementation\ud resources appears less effective. Moving from initial implementation to wider scale-up presents challenges and is an issue that warrants further attention.

International attention has focussed on the variations between research evidence and practice in healthcare. This prompted the creation of formalized translational networks consisting of academic-service partnerships. The English Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) are one example of a translational network. Using longitudinal, archival case study data from one CLAHRC over a 3-year period (2008-11), this article explores the relationship between organizational form and the function(s) of a translational network. The article focuses on the research gaps on the effective structures and appropriate governance to support a translational network. Data analysis suggested that the policy of setting up translational networks is insufficient of itself to produce positive translational activity. The data indicate that to leverage the benefits of the whole network, attention must be paid to devising a structure which integrates research production and use and facilitates lateral cross-disciplinary and cross-organizational communication. Equally, appropriate governance arrangements are necessary, particularly in large, multi-stakeholder networks, where shared governance may be questionable. Inappropriate network structure and governance inhibits the potential of the translational network. Finally, the case provides insights into the movement of knowledge within and between network organizations. The data demonstrate that knowledge mobilization extends beyond knowledge translation; knowledge mobilization includes the negotiated utilization of knowledge - a balanced power form of collaboration. Whilst much translational effort is externally focused on the health system, our findings highlight the essential need for the internal negotiation and mobilization of knowledge within academia.

Debates about knowledge translation (KT) typically focus on the research–practice gap, which appears to be premised on the assumption that academics are a homogeneous collective, sharing a common view. We argue that a number of hidden barriers need to be addressed related to the understanding, interpretation, ability, and commitment to translate knowledge within academic communities. We explore this by presenting a qualitative case study in a health sciences faculty. Applying organizational and management theory, we discuss different types of boundaries and the resultant barriers generated, ranging from diversity in understanding and perceptions of KT to varying motivations and incentives to engage in translational activity. We illustrate how we are using the empirical findings to inform the development of a KT strategy that targets the identified barriers. Investing in this internal KT-focused activity is an important step to maximize the potential of future collaborations between producers and users of research in health care.

Background: Health care practice needs to be underpinned by high quality research evidence, so that the best possible care can be delivered. However, evidence from research is not always utilised in practice. This study used the Promoting Action on Research Implementation in Health Services (PARIHS) framework as its theoretical underpinning to test whether two different approaches to facilitating implementation could affect the use of research evidence in practice.Methods: A pragmatic clustered randomised controlled trial with embedded process and economic evaluation was used. The study took place in four European countries across 24 long-term nursing care sites, for people aged 60 years or more with documented urinary incontinence. In each country, sites were randomly allocated to standard dissemination, or one of two different types of facilitation. The primary outcome was the documented percentage compliance with the continence recommendations, assessed at baseline, then at 6, 12, 18, and 24 months after the intervention.Data were analysed using STATA15, multi-level mixed-effects linear regression models were fitted to scores for compliance with the continence recommendations, adjusting for clustering.Results: Quantitative data were obtained from reviews of 2313 records. There were no significant differences in the primary outcome (documented compliance with continence recommendations) between study arms and all study arms improved over time.Conclusions: This was the first cross European randomised controlled trial with embedded process evaluation that sought to test different methods of facilitation. There were no statistically significant differences in compliance with continence recommendations between the groups. It was not possible to identify whether different types and "doses" of facilitation were influential within very diverse contextual conditions. The process evaluation (Rycroft-Malone et al., Implementation Science. doi: 10.1186/s13012-018-0811-0) revealed the models of facilitation used were limited in their ability to overcome the influence of contextual factors.Trial registration: Current Controlled Trials ISRCTN11598502. Date 4/2/10.The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007–2013) under grant agreement no. 223646.

QUALITY PROBLEM: Undiagnosed chronic kidney disease (CKD) contributes to a high cost and care burden in secondary care. Uptake of evidence-based guidelines in primary care is inconsistent, resulting in variation in the detection and management of CKD. INITIAL ASSESSMENT: Routinely collected general practice data in one UK region suggested a CKD prevalence of 4.1%, compared with an estimated national prevalence of 8.5%. Of patients on CKD registers, ∼ 30% were estimated to have suboptimal management according to Public Health Observatory analyses. CHOICE OF SOLUTION: An evidence-based framework for implementation was developed. This informed the design of an improvement collaborative to work with a sample of 30 general practices. IMPLEMENTATION: A two-phase collaborative was implemented between September 2009 and March 2012. Key elements of the intervention included learning events, improvement targets, Plan-Do-Study-Act cycles, benchmarking of audit data, facilitator support and staff time reimbursement. EVALUATION: Outcomes were evaluated against two indicators: number of patients with CKD on practice registers; percentage of patients achieving evidence-based blood pressure (BP) targets, as a marker for CKD care. In Phase 1, recorded prevalence of CKD in collaborative practices increased ∼ 2-fold more than that in comparator local practices; in Phase 2, this increased to 4-fold, indicating improved case identification. Management of BP according to guideline recommendations also improved. LESSONS LEARNED: An improvement collaborative with tailored facilitation support appears to promote the uptake of evidence-based guidance on the identification and management of CKD in primary care. A controlled evaluation study is needed to rigorously evaluate the impact of this promising improvement intervention.

Background Organisational context is frequently cited as an important consideration when implementing and evaluating quality improvement interventions in healthcare, but limited guidance is available on which aspects of context are most influential or modifiable. This paper examines how internal and external contextual factors mediate organisational-level performance improvement through applying the knowledge-based theory of absorptive capacity (AC). Methods Three healthcare case studies are presented. Each case is a UK National Health Service organisation that had been identified as having performance problems. Qualitative data were collected through semi-structured interviews with general and clinical managers within the organisation and members of external teams supporting or overseeing performance improvement (n=22). Interview data were analysed using an existing AC framework from the literature. Results The organisation with the highest AC showed the quickest and most comprehensive performance improvement. Internal characteristics including strategic priorities, processes for managing information, communication and orientation to learning and development impacted on the organisation's ability to engage successfully with external stakeholders and make use of available knowledge. This enabled the organisation to thrive despite the challenging external environment. Lower levels of AC appeared to delay or limit the improvement trajectory. Conclusions Developing a more detailed and nuanced understanding of how context influences improvement is an important step towards achieving more effective and sustainable quality improvement programmes in healthcare. AC, with its focus on knowledge and organisational learning, provides a useful way to explore the relationship between context and quality improvement and represents a potentially valuable area for future research and development.

Background: There is increasing awareness that regardless of the proven value of clinical interventions, the use of effective strategies to implement such interventions into clinical practice is necessary to ensure that patients receive the benefits. However, there is often confusion between what is the clinical intervention and what is the implementation intervention. This may be caused by a lack of conceptual clarity between 'intervention' and 'implementation', yet at other times by ambiguity in application. We suggest that both the scientific and the clinical communities would benefit from greater clarity; therefore, in this paper, we address the concepts of intervention and implementation, primarily as in clinical interventions and implementation interventions, and explore the grey area in between. Discussion: To begin, we consider the similarities, differences and potential greyness between clinical interventions and implementation interventions through an overview of concepts. This is illustrated with reference to two examples of clinical interventions and implementation intervention studies, including the potential ambiguity in between. We then discuss strategies to explore the hybridity of clinical-implementation intervention studies, including the role of theories, frameworks, models, and reporting guidelines that can be applied to help clarify the clinical and implementation intervention, respectively. Conclusion: Semantics provide opportunities for improved precision in depicting what is 'intervention' and what is 'implementation' in health care research. Further, attention to study design, the use of theory, and adoption of reporting guidelines can assist in distinguishing between the clinical intervention and the implementation intervention. However, certain aspects may remain unclear in analyses of hybrid studies of clinical and implementation interventions. Recognizing this potential greyness can inform further discourse.

Background Chronic kidney disease (CKD) is common and a significant marker of morbidity and mortality. Its management in primary care is essential for maintenance of cardiovascular health, avoidance of acute kidney injury (AKI) and delay in progression to end-stage renal disease. Although many guidelines and interventions have been established, there is global evidence of an implementation gap, including variable identification rates and low patient communication and awareness. The objective of this study is to understand the factors enabling and constraining the implementation of CKD interventions in primary care. Methods A rapid realist review was conducted that involved a primary literature search of three databases to identify existing CKD interventions in primary care between the years 2000 and 2014. A secondary search was performed as an iterative process and included bibliographic and grey literature searches of reference lists, authors and research groups. A systematic approach to data extraction using Normalisation Process Theory (NPT) illuminated key mechanisms and contextual factors that affected implementation. Results Our primary search returned 710 articles that were narrowed down to 18 relevant CKD interventions in primary care. Our findings suggested that effective management of resources (encompassing many types) was a significant contextual factor enabling or constraining the functioning of mechanisms. Three key intervention features were identified from the many that contributed to successful implementation. Firstly, it was important to frame CKD interventions appropriately, such as within the context of cardiovascular health and diabetes. This enabled buy-in and facilitated an understanding of the significance of CKD and the need for intervention. Secondly, interventions that were compatible with existing practices or patients’ everyday lives were readily accepted. In contrast, new systems that could not be integrated were abandoned as they were viewed as inconvenient, generating more work. Thirdly, ownership of the feedback process allowed users to make individualised improvements to the intervention to suit their needs. Conclusions Our rapid realist review identified mechanisms that need to be considered in order to optimise the implementation of interventions to improve the management of CKD in primary care. Further research into the factors that enable prolonged sustainability and cost-effectiveness is required for efficient resource utilisation. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0413-7) contains supplementary material, which is available to authorized users.

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.

Objective This study evaluated Leading 4 Change, a change leadership development program designed to support healthcare middle managers through a period of significant organisational change and enhance workplace resilience. Methods A mixed methods evaluation was conducted within the program’s framework of a quality improvement activity. Quantitative measures were participant responses (n=160) to online questionnaires, which were compared before and after the program, using an uncontrolled pre-post study design. Four questionnaires were used: Resilience @ Work, General Self-Efficacy, the 11-item Learning Organization Survey and organisational climate. Differences between the pre- and post-program periods were compared using linear mixed-effects models, incorporating repeated measures between ‘pre’ and ‘post’ periods. Qualitative data were obtained by interviewing four participants on three occasions during the program, and through text responses provided by participants during a presentation session after the program finished. Both interview data and textual data were subjected to thematic analysis. Results Integration of data from quantitative and qualitative analyses generated three main findings: (1) participants were satisfied and engaged with the program, which met their learning objectives; (2) the program led to increased workplace resilience, in particular the ability to manage stress and self-efficacy for individuals; and (3) organisational learning perceptions were unchanged. Conclusion Although conducted during a period of intense internal and external pressure, Leading 4 Change led to demonstrable effects. It effectively engaged middle managers across a health system. However, there was no evidence that the effect of the program extended beyond individual participants to their perceptions of their work environment as a learning organisation. What is known about the topic? Although much has been written about change management and change leadership within healthcare, the failure to manage the ‘people’ element and engage employees hampers the success of that change. However, how to engage employees and enhance their resilience and self-efficacy (self-belief to proactively manage) during change has been little explored. Further, the concept of a learning organisation has been developed in private, non-healthcare fields and there is little known about it in other areas, such as healthcare, particularly during change. What does this paper add? The paper describes the evaluation of a 16-week change leadership development program (Leading 4 Change) for middle managers of a public health system undergoing significant reform. It assesses how the program engaged employees, and how and to what extent their workplace resilience, self-efficacy and perceptions of their workplace as a learning organisation changed after the program. Based on the present study, individual development of staff does not necessarily translate directly to better staff perceptions of organisational outcomes. What are the implications for practitioners? Despite being clearly engaged with Leading 4 Change, quantitative and qualitative measures suggested mixed effects of the program on participants. Participants’ self-rated workplace resilience, ability to manage stress and self-efficacy increased after the program. However, there was no evidence that the effect of the program improved staff perceptions of their work as a learning organisation. For complex public sector healthcare organisations to become learning organisations, other organisational factors, in addition to staff development and training, require consideration.

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

This paper explores the ways in which technological innovation becomes adopted and incorporated into healthcare practice. Drawing upon the notion of ‘field of practices’, we examine how adoption is subject to spatially and temporally distributed reconfigurations across a multi-level set of practices, ranging from the policy level to the micro-level setting of individual action. The empirical backdrop is provided by a case study of the adoption of Breast Lymph Node Assay (BLNA), a diagnostic technology innovation for the treatment of breast cancer patients. Our aim is to contribute to the development of a more comprehensive analysis of the processes surrounding the adoption and incorporation of complex healthcare technologies into routine practice.

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.

Many nurses in a variety of clinical settings are facing the challenges posed by incorporating evidence-based practice in health care. Some of the steps involved in implementing evidence-based care in clinical practice are discussed and a two-step framework to assist practitioners in implementing evidence-based practice is outlined. Factors such as the relevance of specific guidelines or research, generalisability of research findings, the strength of the evidence relative to the risks and benefits of treatment, and patient preferences are discussed in terms of evidence-based decision making.

To evaluate the clinical application of national guidelines for neonatal nursing.Questionnaire survey.Thirty-nine neonatal care units in Sweden.Thirty-five of 39 nurse managers at all Swedish neonatal care units.Thirteen clinical guidelines for neonatal nursing care were presented in 1997. Recommendations on evidence-based nursing care and auditing measures were given. Most neonatal units in Sweden participated in the guideline development.Extent of guideline application, ways in which the guidelines were used and perceived usefulness.The guidelines were applied to different extents in 30 of the 35 units. Almost all the guidelines were applied, especially those covering general nursing care. In total, 72 Quality Improvement (QI) projects were reported, of which 51 concerned specific topics covered in the guidelines. Twenty units applied the guidelines as a starting point for QI. Four units evaluated nursing practice against the guidelines. Four factors [Dynamic Standard Setting System (DySSSy) as the QI method,or = 4 years of practice as nurse manager, experience of nursing research, and good staff resources] were closely related to a more extensive application of the guidelines. Units with both a nurse manager and an assistant nurse manager were more likely to have used the guidelines as the basis for changing clinical practice.The guidelines were successfully disseminated and diffused, but practitioner involvement in guideline development did not guarantee implementation. Downsizing, leadership and facilitation seemed to be crucial factors when getting evidence into practice. Limited occurrence of evaluations of clinical practice against guideline recommendations suggests a need for valid and user-friendly measures.

Background Effective implementation of change in healthcare organisations involves multiple professional and organisational groups and is often impeded by professional and organisational boundaries that present relatively impermeable barriers to sharing knowledge and spreading work practices. Informed by the theory of communities of practice (CoPs), this study explored the effects of intra-organisational and inter-organisational boundaries on the implementation of service improvement within and across primary healthcare settings and on the development of multiprofessional and multi-organisational CoPs during this process. Methods The study was conducted within the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester—a collaborative partnership between the University of Manchester and local National Health Service organisations aiming to undertake applied health research and enhance its implementation in clinical practice. It deployed a qualitative embedded case study design, encompassing semistructured interviews, direct observation and documentary analysis, conducted in 2010–2011. The sample included practice doctors, nurses, managers and members of the CLAHRC implementation team. Findings The study showed that in spite of epistemic and status differences, professional boundaries between general practitioners, practice nurses and practice managers co-located in the same practice over a relatively long period of time could be successfully bridged, leading to the formation of multiprofessional CoPs. While knowledge circulated relatively easily within these CoPs, barriers to knowledge sharing emerged at the boundary separating them from other groups existing in the same primary care setting. The strongest boundaries, however, lay between individual general practices, with inter-organisational knowledge sharing and collaboration between them remaining unequally developed across different areas due to historical factors, competition and strong organisational identification. Manipulated emergence of multi-organisational CoPs in the context of primary care may thus be problematic. Conclusions In cases when manipulated emergence of new CoPs is problematic, boundary issues could be addressed by adopting a developmental perspective on CoPs, which provides an alternative to the analytical and instrumental perspectives previously described in the CoP literature. This perspective implies a pragmatic, situational approach to mapping existing CoPs and their characteristics and potentially modifying them in the process of service improvement through the combination of internal and external facilitation.

Research has demonstrated a knowledge and practice gap in the identification and management of chronic kidney disease (CKD). In 2009, published data showed that general practices in Greater Manchester had a low detection rate for CKD.A 12-month improvement collaborative, supported by an evidence-informed implementation framework and financial incentives.19 general practices from four primary care trusts within Greater Manchester.Number of recorded patients with CKD on practice registers; percentage of patients on registers achieving nationally agreed blood pressure targets.The collaborative commenced in September 2009 and involved three joint learning sessions, interspersed with practice level rapid improvement cycles, and supported by an implementation team from the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Greater Manchester.At baseline, the 19 collaborative practices had 4185 patients on their CKD registers. At final data collection in September 2010, this figure had increased by 1324 to 5509. Blood pressure improved from 34% to 74% of patients on practice registers having a recorded blood pressure within recommended guidelines.Evidence-based improvement can be implemented in practice for chronic disease management. A collaborative approach has been successful in enabling teams to test and apply changes to identify patients and improve care. The model has proved to be more successful for some practices, suggesting a need to develop more context-sensitive approaches to implementation and actively manage the factors that influence the success of the collaborative.

Background Research evidence underpins best practice, but is not always used in healthcare. The Promoting Action on Research Implementation in Health Services (PARIHS) framework suggests that the nature of evidence, the context in which it is used, and whether those trying to use evidence are helped (or facilitated) affect the use of evidence. Urinary incontinence has a major effect on quality of life of older people, has a high prevalence, and is a key priority within European health and social care policy. Improving continence care has the potential to improve the quality of life for older people and reduce the costs associated with providing incontinence aids. Objectives This study aims to advance understanding about the contribution facilitation can make to implementing research findings into practice via: extending current knowledge of facilitation as a process for translating research evidence into practice; evaluating the feasibility, effectiveness, and cost-effectiveness of two different models of facilitation in promoting the uptake of research evidence on continence management; assessing the impact of contextual factors on the processes and outcomes of implementation; and implementing a pro-active knowledge transfer and dissemination strategy to diffuse study findings to a wide policy and practice community. Setting and sample Four European countries, each with six long-term nursing care sites (total 24 sites) for people aged 60 years and over with documented urinary incontinence Methods and design Pragmatic randomised controlled trial with three arms (standard dissemination and two different programmes of facilitation), with embedded process and economic evaluation. The primary outcome is compliance with the continence recommendations. Secondary outcomes include proportion of residents with incontinence, incidence of incontinence-related dermatitis, urinary tract infections, and quality of life. Outcomes are assessed at baseline, then at 6, 12, 18, and 24 months after the start of the facilitation interventions. Detailed contextual and process data are collected throughout, using interviews with staff, residents and next of kin, observations, assessment of context using the Alberta Context Tool, and documentary evidence. A realistic evaluation framework is used to develop explanatory theory about what works for whom in what circumstances. Trial registration Current Controlled Trials ISRCTN11598502.

Background: The English National Health Service has made a major investment in nine partnerships between\ud higher education institutions and local health services called Collaborations for Leadership in Applied Health\ud Research and Care (CLAHRC). They have been funded to increase capacity and capability to produce and\ud implement research through sustained interactions between academics and health services. CLAHRCs provide a\ud natural ‘test bed’ for exploring questions about research implementation within a partnership model of delivery.\ud This protocol describes an externally funded evaluation that focuses on implementation mechanisms and\ud processes within three CLAHRCs. It seeks to uncover what works, for whom, how, and in what circumstances.\ud Design and methods: This study is a longitudinal three-phase, multi-method realistic evaluation, which\ud deliberately aims to explore the boundaries around knowledge use in context. The evaluation funder wishes to see\ud it conducted for the process of learning, not for judging performance. The study is underpinned by a conceptual\ud framework that combines the Promoting Action on Research Implementation in Health Services and Knowledge to\ud Action frameworks to reflect the complexities of implementation. Three participating CLARHCS will provide indepth\ud comparative case studies of research implementation using multiple data collection methods including\ud interviews, observation, documents, and publicly available data to test and refine hypotheses over four rounds of\ud data collection. We will test the wider applicability of emerging findings with a wider community using an\ud interpretative forum.\ud Discussion: The idea that collaboration between academics and services might lead to more applicable health\ud research that is actually used in practice is theoretically and intuitively appealing; however the evidence for it is\ud limited. Our evaluation is designed to capture the processes and impacts of collaborative approaches for\ud implementing research, and therefore should contribute to the evidence base about an increasingly popular (e.g.,\ud Mode two, integrated knowledge transfer, interactive research), but poorly understood approach to knowledge\ud translation. Additionally we hope to develop approaches for evaluating implementation processes and impacts\ud particularly with respect to integrated stakeholder involvement.

Background The paper combines the analytical and instrumental perspectives on communities of practice (CoPs) to reflect on potential challenges that may arise in the process of interprofessional and inter-organisational joint working within the Collaborations for Leaderships in Applied Health Research and Care (CLAHRCs)--partnerships between the universities and National Health Service (NHS) Trusts aimed at conducting applied health research and translating its findings into day-to-day clinical practice. Discussion The paper discusses seminal theoretical literature on CoPs as well as previous empirical research on the role of these communities in healthcare collaboration, which is organised around the following three themes: knowledge sharing within and across CoPs, CoP formation and manageability, and identity building in CoPs. It argues that the multiprofessional and multi-agency nature of the CLAHRCs operating in the traditionally demarcated organisational landscape of the NHS may present formidable obstacles to knowledge sharing between various professional groupings, formation of a shared 'collaborative' identity, and the development of new communities within the CLAHRCs. To cross multiple boundaries between various professional and organisational communities and hence enable the flow of knowledge, the CLAHRCs will have to create an effective system of 'bridges' involving knowledge brokers, boundary objects, and cross-disciplinary interactions as well as address a number of issues related to professional and organisational identification. Summary The CoP approach can complement traditional 'stage-of-change' theories used in the field of implementation research and provide a basis for designing theory-informed interventions and evaluations. It can help to illuminate multiple boundaries that exist between professional and organisational groups within the CLAHRCs and suggest ways of crossing those boundaries to enable knowledge transfer and organisational learning. Achieving the aims of the CLAHRCs and producing a sustainable change in the ways applied health research is conducted and implemented may be influenced by how effectively these organisations can navigate through the multiple CoPs involved and promote the development of new multiprofessional and multi-organisational communities united by shared practice and a shared sense of belonging--an assumption that needs to be explored by further empirical research.

Item does not contain fulltext Evaluation is an integral component of quality improvement and there is much to be learned from the evaluation of small scale quality improvement initiatives at a local level. This type of evaluation is useful for a number of different reasons including monitoring the impact of local projects, identifying and dealing with issues as they arise within a project, comparing local projects to draw lessons, and collecting more detailed information as part of a bigger evaluation project. Focused audits and developmental studies can be used for evaluation within projects, while methods such as multiple case studies and process evaluations can be used to draw generalised lessons from local experiences and to provide examples of successful projects. Evaluations of small scale quality improvement projects help those involved in improvement initiatives to optimise their choice of interventions and use of resources. Important information to add to the knowledge base of quality improvement in health care can be derived by undertaking formal evaluation of local projects, particularly in relation to building theory around the processes of implementation and increasing understanding of the complex change processes involved.

Mounting pressure is being exerted to ensure that the delivery of care is evidence-based and clinically effective. However, the challenge this presents to practitioners is complex. The authors propose that successful implementation of evidence into practice is a function of three elements: the nature of the evidence; the context in which the change is to take place; and the way the process is managed. A framework has been developed to represent these factors. For those about to embark on implementation work, this article closes by highlighting a number of key questions for consideration, stimulated by the framework.

Getting evidence into practice: the meaning of `context' Aim of paper. This paper presents the findings of a concept analysis of `context' in relation to the successful implementation of evidence into practice. Background. In 1998, a conceptual framework was developed that represented the interplay and interdependence of the many factors influencing the uptake of evidence into practice [Kitson A., Harvey G. & McCormack B. (1998) Quality in Health Care7, 149]. One of the key elements of the framework was `context', that is, the setting in which evidence is implemented. It was proposed that key factors in the context of health care practice had a significant impact on the implementation and uptake of evidence. 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 some theoretical and conceptual rigour to its content. Methods. Morse's [Morse J.M. (1995) Advances in Nursing Science17, 31; Morse J.M., Hupcey J.E. & Mitcham C. (1996) Scholarly Inquiry for Nursing Practice. An International Journal10, 253] approach to concept analysis was used as a framework to review semi-nal texts critically and the supporting research literature in order to establish the conceptual clarity and maturity of `context' in relation to its importance in the implementation of evidence-based practice. Findings: Characteristics of the concept of context in terms of organizational culture, leadership and measurement are outlined. A main finding is that context specifically means `the setting in which practice takes place', but that the term itself does little to reflect the complexity of the concept. Whilst the themes of culture and leadership are central characteristics of the concept, the theme of `measurement' is better articulated through the broader term of `evaluation'. Conclusions. There is inconsistency in the use of the term and this has an impact on claims of its importance. The concept of context lacks clarity because of the many issues that impact on the way it is characterized. Additionally, there is limited understanding of the consequences of working with different contexts. Thus, the implications of using context as a variable in research studies exploring research implementation are as yet largely unknown. The concept of context is partially developed but in need of further delineation and comparison.

Care pathways are increasingly being used in the UK as a tool for managing clinical processes and patient outcomes. This article describes some of the key elements of care pathways, highlights factors in successful implementation and discusses some concerns about their use.

A tool was developed, using the nominal group and Delphi techniques, to explore healthcare staff's perceptions of the quality of hospital care provided in the United Kingdom compared with a tool from the United States. Similarities were identified in many core areas; however, there were several differences between the UK and US tools. This article identifies the process and findings and discusses possible reasons for similarities and differences between the tools.

In tracing developments in health care quality, a number of different approaches to quality evaluation can be identified, differing in terms of the specific focus and means of achieving quality. This paper attempts to classify the development of quality in health care, drawing on experiences within the industrial quality movement. Three distinct models of quality evaluation are described, according to whether they define quality at an individual level, as an exercise in inspection, or as a method for continuous improvement. Developments in quality and audit in health care are explored in relation to the models and specific experiences within nursing and medicine are compared. The need to be aware of the history of quality within specific professional groups is highlighted, particularly within the context of future developments in health care quality and the growing focus on multi-professional collaboration.

Objective: To evaluate a strategy for supporting nurses to work with quality improvement (QI). Design: Post-intervention evaluation. Study participants and intervention: 240 nurses participated in a uniformly designed 4 day basic training course in applying a model for QI. Of these, 156 nurses from over 50 healthcare institutions constituted the generic education (GE) group while 84 nurses from 42 neonatal units took part in a project to develop national guidelines, constituting the targeted intervention (TI) group. Method: Postal questionnaire 4 years after the training courses. Results: The response rate was 80% in the TI group and 64% in the GE group. Nurses in the TI group had a significantly higher rate in completing all phases of the QI cycle (p=0.0002). With no differences between the groups, 39% of all nurses were still involved in QI work 4 years after the training courses. Three factors were significantly related to nurses continuing their involvement in QI projects: remaining employed on the same unit (OR 11.3), taking courses in nursing science (OR 4.1), and maintenance of the same QI model (OR 3.1). Reported motives for remaining active in QI work were the enhancement of knowledge, influence over clinical practice, and development as a nurse. Reasons for discontinuation were organisational restructuring, a lack of facilitation and knowledge, and change of workplace. Conclusions: Participation in a national guideline project, including a common focus for improvement, facilitation and opportunities for networking, seems to have enhanced the ability to carry out the process of QI, but not to sustain the QI work over a longer period.