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BackgroundMost hospitals use physiological signs to trigger an urgent clinical review. We investigated whether facilitation could improve nurses’ vital sign measurement, interpretation, treatment and escalation of care for deteriorating patients.MethodsIn a pragmatic cluster randomised controlled trial, we randomised 36 inpatient wards at four acute hospitals to receive standard clinical practice guideline (CPG) dissemination to ward staff (n=18) or facilitated implementation for 6 months following standard dissemination (n=18). Expert, hospital and ward facilitators tailored facilitation techniques to promote nurses’ CPG adherence. Patient records were audited pre-intervention, 6 and 12 months post-intervention on randomly selected days. Escalation of care as per hospital policy was the primary outcome at 6 and 12 months after implementation. Patients, nurses and assessors were blinded to group assignment. Analysis was by intention-to-treat.ResultsFrom 10 383 audits, improved escalation as per hospital policy was evident in the intervention group at 6 months (OR 1.47, 95% CI (1.06 to 2.04)) with a complete set of vital sign measurements sustained at 12 months (OR 1.22, 95% CI (1.02 to 1.47)). There were no significant differences in escalation of care as per hospital policy between study groups at 6 or 12 months post-intervention. After adjusting for patient and hospital characteristics, a significant change from T0 in mean length of stay between groups at 12 months favoured the intervention group (−2.18 days, 95% CI (−3.53 to –0.82)).ConclusionMulti-level facilitation significantly improved escalation as per hospital policy at 6 months in the intervent

BACKGROUND: Most hospitals use physiological signs to trigger an urgent clinical review. We investigated whether facilitation could improve nurses' vital sign measurement, interpretation, treatment and escalation of care for deteriorating patients. METHODS: In a pragmatic cluster randomised controlled trial, we randomised 36 inpatient wards at four acute hospitals to receive standard clinical practice guideline (CPG) dissemination to ward staff (n=18) or facilitated implementation for 6 months following standard dissemination (n=18). Expert, hospital and ward facilitators tailored facilitation techniques to promote nurses' CPG adherence. Patient records were audited pre-intervention, 6 and 12 months post-intervention on randomly selected days. Escalation of care as per hospital policy was the primary outcome at 6 and 12 months after implementation. Patients, nurses and assessors were blinded to group assignment. Analysis was by intention-to-treat. RESULTS: From 10 383 audits, improved escalation as per hospital policy was evident in the intervention group at 6 months (OR 1.47, 95% CI (1.06 to 2.04)) with a complete set of vital sign measurements sustained at 12 months (OR 1.22, 95% CI (1.02 to 1.47)). There were no significant differences in escalation of care as per hospital policy between study groups at 6 or 12 months post-intervention. After adjusting for patient and hospital characteristics, a significant change from T0 in mean length of stay between groups at 12 months favoured the intervention group (-2.18 days, 95% CI (-3.53 to -0.82)). CONCLUSION: Multi-level facilitation significantly improved escalation as per hospital policy at 6 months in the intervention group that was not sustained at 12 months. The intervention group had increased vital sign measurement by nurses, as well as shorter lengths of stay for patients at 12 months. Further research is required to understand the dose of facilitation required to impact clinical practice behaviours and patient

BACKGROUND: The Medical Research Council published the second edition of its framework in 2006 on developing and evaluating complex interventions. Since then, there have been considerable developments in the field of complex intervention research. The objective of this project was to update the framework in the light of these developments. The framework aims to help research teams prioritise research questions and design, and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods. METHODS: There were four stages to the update: (1) gap analysis to identify developments in the methods and practice since the previous framework was published; (2) an expert workshop of 36 participants to discuss the topics identified in the gap analysis; (3) an open consultation process to seek comments on a first draft of the new framework; and (4) findings from the previous stages were used to redraft the framework, and final expert review was obtained. The process was overseen by a Scientific Advisory Group representing the range of relevant National Institute for Health Research and Medical Research Council research investments. RESULTS: Key changes to the previous framework include (1) an updated definition of complex interventions, highlighting the dynamic relationship between the intervention and its context; (2) an emphasis on the use of diverse research perspectives: efficacy, effectiveness, theory-based and systems perspectives; (3) a focus on the usefulness of evidence as the basis for determining research perspective and questions; (4) an increased focus on interventions developed outside research teams, for example changes in policy or health services delivery; and (5) the identification of six 'core elements' that should guide all phases of complex intervention research: consider context; develop, refine and test programme theory; engage stakeholders; identify key uncertainties; refine the intervention

The UK Medical Research Council’s widely used guidance for developing and evaluating complex interventions has been replaced by a new framework, commissioned jointly by the Medical Research Council and the National Institute for Health Research, which takes account of recent developments in theory and methods and the need to maximise the efficiency, use, and impact of research.

BACKGROUND: The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework. METHODS: This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail. RESULTS: The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated. CONCLUSIONS: In line with previous citation analysis of the use of theoretical frameworks in implementation

Background: The uptake of evidence-based knowledge in practice is influenced by context. Observations are suggested as a valuable but under-used approach in implementation research for gaining a holistic understanding of contexts. Aim: The aim of this paper is to demonstrate how data from observations can provide insights about context and evidence use in implementation research. Methods: Data were collected over 24 months in a randomised trial with an embedded realist evaluation in 24 nursing homes across four European countries; notes from 183 observations (representing 335 hours) were triangulated with interview transcripts and context survey data (from 357 staff interviews and 725 questionnaire responses, respectively). Results: Although there were similarities in several elements of context within survey, interview and observation data, the observations provided additional features of the implementation context. In particular, observations demonstrated if and how the resources (staffing and supplies) and leadership (formal and informal, teamwork, and professional autonomy) affected knowledge use and implementation. Further, the observations illuminated the influence of standards and the physical nursing environment on evidence-based practice, and the dynamic interaction between different aspects of context. Linking Evidence to Action: Although qualitative observations are resource-intensive, they add value when used with other data collection methods, further enlightening the understanding of the implementation context and how evidence use and sharing are influenced by context elements. Observations can enhance an understanding of the context, evidence use and knowledge-sharing triad in implementation research. © 2020 The Authors. Worldviews on Evidence-based Nursing published by Wiley Periodicals LLC on behalf of Sigma Theta Tau International

The ambition of the Canadian Institutes for Health Research Health System Impact (HSI) Fellowship initiative to modernise the health system is impressive. Embedded researchers who work between academia and non-academic settings offer an opportunity to reframe the problem of evidence uptake as a product of a gap between those who produce knowledge and those who use it. As such, there has been an increasing interest in the potential of people in embedded research roles to work with stakeholders in the co-production of knowledge to address service challenges. In this commentary, we draw on research and experiential evidence of an embedded researcher initiative, which has similar intentions to the HSI Fellowships programme: the National Institute for Health Research (NIHR) Knowledge Mobilisation Research Fellowship (KMRF) scheme. We outline the similarities and differences between the two schemes, and then consider the work, characteristics and skills, and organisational arrangements evident in operationalising these types of roles. © 2020 The Author(s); Published by Kerman University of Medical Sciences.

1 januari 2019, Contains fulltext : 215452.pdf (publisher's version ) (Closed access), Generating and implementing evidence-based policy is an important aim for many publicly funded health systems. In dentistry, this is based on the assumption that evidence-based health care increases the efficiency and effectiveness of interventions to improve oral health at a population level. This article argues that a linear logic model that links the generation of research evidence with its use is overly simplistic. It also challenges an uncritical interpretation of the evidence-based paradigm and explores approaches to the evaluation of complex interventions and how they can be embedded into policy and practice to improve oral health at a population level.

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) rev

BACKGROUND: Vital signs are the primary indicator of physiological status and for determining the need for urgent clinical treatment. Yet, if physiological signs of deterioration are missed, misinterpreted or mismanaged, then critical illness, unplanned intensive care admissions, cardiac arrest and death may ensue. Although evidence demonstrates the benefit of early recognition and management of deteriorating patients, failure to escalate care and manage deteriorating patients remains a relatively frequent occurrence in hospitals. METHODS/DESIGN: A pragmatic cluster-randomised controlled trial design will be used to measure clinical effectiveness and cost of a facilitation intervention to improve nurses' vital sign measurement, interpretation, treatment and escalation of care for patients with abnormal vital signs. A cost consequence analysis will evaluate the intervention cost and effectiveness, and a process evaluation will determine how the implementation of the intervention contributes to outcomes. We will compare clinical outcomes and costs from standard implementation of clinical practice guidelines (CPGs) to facilitated implementation of CPGs. The primary outcome will be adherence to the CPGs by nurses, as measured by escalation of care as per organisational policy. The study will be conducted in four Australian major metropolitan teaching hospitals. In each hospital, eight to ten wards will be randomly allocated to intervention and control groups. Control wards will receive standard implementation of CPGs, while intervention wards will receive standard CPG implementation plus facilitation, using facilitation methods and processes tailored to the ward context. The intervention will be administered to all nursing staff at the ward level for 6 months. At each hospital, two types of facilitators will be provided: a hospital-level facilitator as the lead; and two ward-level facilitators for each ward. DISCUSSION: This study uses an innovative, networked approach

Over time there has been a shift, at least in the rhetoric, from a pipeline conceptualisation of knowledge implementation, to one that recognises the potential of more collaboration, co-productive approaches to knowledge production and use. In this editorial, which is grounded in our research and collective experience, we highlight both the potential and challenge with collaboration and co-production. This includes issues about stakeholder engagement, governance arrangements, and capacity and capability for working in a co-productive way. Finally, we reflect on the fact that this approach is not a panacea, but is accompanied by some philosophical and practical challenges. Copyright © 2016 by Kerman University of Medical Sciences.

Background Eighty per cent of care home residents in the UK are living with dementia. The prevalence of faecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes. Objective To provide a theory-driven explanation of the effectiveness of programmes that aim to improve FI in people with advanced dementia in care homes. Design A realist synthesis. This was an iterative approach that involved scoping of the literature and consultation with five stakeholder groups, a systematic search and analysis of published and unpublished evidence, and a validation of programme theories with relevant stakeholders. Data sources The databases searched included PubMed, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Scopus, SocAbs, Applied Social Sciences Index and Abstracts, BiblioMap, Sirius, OpenGrey, Social Care Online and the National Research Register. Results The scoping identified six programme theories with related context–mechanism–outcome configurations for testing. These addressed (1) clinician-led support, assessment and review, (2) the contribution of teaching and support for care home staff on how to reduce and manage FI, (3) the causes and prevention of constipation, (4) how the cognitive and physical capacity of the resident affect outcomes, (5) how the potential for recovery, reduction and management of FI is understood by those involved and (6) how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Data extraction was completed on 62 core papers with iterative searches of linked literature. Dementia was a known risk factor for FI, but its affect on the uptake of different interventions and the dementia-specific continence and toileting skills staff required was not addressed. Most care home residents with FI will be doubly incontinent and, therefore, t

BACKGROUND: Vital signs are the primary indicator of physiological status and for determining the need for urgent clinical treatment. Yet, if physiological signs of deterioration are missed, misinterpreted or mismanaged, then critical illness, unplanned intensive care admissions, cardiac arrest and death may ensue. Although evidence demonstrates the benefit of early recognition and management of deteriorating patients, failure to escalate care and manage deteriorating patients remains a relatively frequent occurrence in hospitals. METHODS/DESIGN: A pragmatic cluster-randomised controlled trial design will be used to measure clinical effectiveness and cost of a facilitation intervention to improve nurses' vital sign measurement, interpretation, treatment and escalation of care for patients with abnormal vital signs. A cost consequence analysis will evaluate the intervention cost and effectiveness, and a process evaluation will determine how the implementation of the intervention contributes to outcomes. We will compare clinical outcomes and costs from standard implementation of clinical practice guidelines (CPGs) to facilitated implementation of CPGs. The primary outcome will be adherence to the CPGs by nurses, as measured by escalation of care as per organisational policy. The study will be conducted in four Australian major metropolitan teaching hospitals. In each hospital, eight to ten wards will be randomly allocated to intervention and control groups. Control wards will receive standard implementation of CPGs, while intervention wards will receive standard CPG implementation plus facilitation, using facilitation methods and processes tailored to the ward context. The intervention will be administered to all nursing staff at the ward level for 6 months. At each hospital, two types of facilitators will be provided: a hospital-level facilitator as the lead; and two ward-level facilitators for each ward. DISCUSSION: This study uses an innovative, networked approach

Contains fulltext : 165909.pdf (publisher's version ) (Open Access)

BackgroundEmerging evidence focuses on the importance of the role of leadership in successfully transferring research evidence into practice. However, little is known about the interaction between managerial leaders and clinical leaders acting as facilitators (internal facilitators [IFs]) in this implementation process. AimsTo describe the interaction between managerial leaders and IFs and how this enabled or hindered the facilitation process of implementing urinary incontinence guideline recommendations in a local context in settings that provide long-term care to older people. MethodsSemistructured interviews with 105 managers and 22 IFs, collected for a realist process evaluation across four European countries informed this study. An interpretive data analysis unpacks interactions between managerial leaders and IFs. ResultsThis study identified three themes that were important in the interactions between managerial leaders and IFs that could hinder or support the implementation process: realising commitment; negotiating conditions; and encouragement to keep momentum going. The findings revealed that the continuous reciprocal relationships between IFs and managerial leaders influenced the progress of implementation, and could slow the process down or disrupt it. A metaphor of crossing a turbulent river by the building of a bridge emerged as one way of understanding the findings. Linking Evidence to ActionOur findings illuminate a neglected area, the effects of relationships between key staff on implementing evidence into practice. Relational aspects of managerial and clinical leadership roles need greater consideration when planning guideline implementation and practice change. In order to support implementation, staff assigned as IFs as well as stakeholders like managers at all levels of an organisation should be engaged in realising commitment, negotiating conditions, and keeping momentum going. Thus, communication is crucial between all involved.

Aim To examine the application of core concepts from Complexity Theory to explain the findings from a process evaluation undertaken in a trial evaluating implementation strategies for recommendations about reducing surgical fasting times. Background The proliferation of evidence‐based guidance requires a greater focus on its implementation. Theory is required to explain the complex processes across the multiple healthcare organizational levels. This social healthcare context involves the interaction between professionals, patients and the organizational systems in care delivery. Complexity Theory may provide an explanatory framework to explain the complexities inherent in implementation in social healthcare contexts. Design A secondary thematic analysis of qualitative process evaluation data informed by Complexity Theory. Method Seminal texts applying Complexity Theory to the social context were annotated, key concepts extracted and core Complexity Theory concepts identified. These core concepts were applied as a theoretical lens to provide an explanation of themes from a process evaluation of a trial evaluating the implementation of strategies to reduce surgical fasting times. Sampled substantive texts provided a representative spread of theoretical development and application of Complexity Theory from late 1990's–2013 in social science, healthcare, management and philosophy. Findings Five Complexity Theory core concepts extracted were ‘self‐organization’, ‘interaction’, ‘emergence’, ‘system history’ and ‘temporality’. Application of these concepts suggests routine surgical fasting practice is habituated in the social healthcare system and therefore it cannot easily be reversed. A reduction to fasting times requires an incentivised new approach to emerge in the surgical system's priority of completing the operating list. Conclusion The application of Complexity Theory provides a useful explanation for resistance to change fasting practice. Its utility in implementa

Worldwide, the prevalences of diabetes and dementia are both increasing, particularly in older people. Rates of diabetes in people with dementia are between 13 and 20 %. Diabetes management and diabetic self-care may be adversely affected by the presence of dementia. There is a need to know what interventions work best in the management of diabetes in people living with dementia (PLWD) in different settings and at different stages of the dementia trajectory. The overall aim is to develop an explanatory account or programme theory about ‘what works’ in the management of diabetes in people in what context and to identify promising interventions that merit further evaluation.

Objectives This evidence review was conducted to understand how and why workforce development interventions can improve the skills and care standards of support workers in older people's services. Design Following recognised realist synthesis principles, the review was completed by (1) development of an initial programme theory; (2) retrieval, review and synthesis of evidence relating to interventions designed to develop the support workforce; (3) ‘testing out’ the synthesis findings to refine the programme theories, and establish their practical relevance/potential for implementation through stakeholder interviews; and (4) forming actionable recommendations. Participants Stakeholders who represented services, commissioners and older people were involved in workshops in an advisory capacity, and 10 participants were interviewed during the theory refinement process. Results Eight context–mechanism–outcome (CMO) configurations were identified which cumulatively comprise a new programme theory about ‘what works’ to support workforce development in older people's services. The CMOs indicate that the design and delivery of workforce development includes how to make it real to the work of those delivering support to older people; the individual support worker's personal starting points and expectations of the role; how to tap into support workers' motivations; the use of incentivisation; joining things up around workforce development; getting the right mix of people engaged in the design and delivery of workforce development programmes/interventions; taking a planned approach to workforce development, and the ways in which components of interventions reinforce one another, increasing the potential for impacts to embed and spread across organisations. Conclusions It is important to take a tailored approach to the design and delivery of workforce development that is mindful of the needs of older people, support workers, health and social care services and the employing orga

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

Rationale Besides a growing demand for safe high-quality care for older people, long-term care (LTC) often struggles to recruit appropriately qualified nursing staff. Understanding what LTC staff value in their work may contribute to a more comprehensive understanding of what can attract staff and support person-centred care. Aim To explore staff experience of the advantages of working in LTC settings for older people. Methods Narrative descriptions of 85 LTC staff in Ireland, the Netherlands and Sweden on what they value in their work were analysed with qualitative content analysis. Ethics Ethical approval was obtained according to the requirements of each country, and participants provided informed consent prior to the individual interviews. Findings Working in LTC signifies bonding with the older people residing there, their next of kin and the team members. It means autonomy in one's daily tasks amalgamated with being a part of an affirmative team. Participants reported a sense of accomplishment and fulfilment; caring meant consideration and recognition of the older people and the relationships formed, which provided for professional and personal growth. The sharing of compassion between staff and residents indicated reciprocity of the relationship with residents. Study limitations The findings may be transferable to LTC in general although they address only the positive aspects of caring for older people and only the experiences of those staff who had consented to take part in the study. Conclusions The findings add to what underpins the quality of care in nursing homes: compassion in the nurse–resident relationship and person-centred care in LTC. They indicate reciprocity in the relations formed that may contribute to the empowerment of older people, but further studies are needed to explore this in more detail.

Introduction: Faecal incontinence (FI) is the involuntary loss of liquid or solid stool that is a social or hygienic problem. The prevalence of FI in residents of care homes is high, but it is not an inevitable consequence of old age or dementia. There is good evidence on risk factors, but few studies provide evidence about effective interventions. There is a need to understand how, why, and in what circumstances particular programmes to reduce and manage FI are effective (or not) for people with dementia. The purpose of this review is to identify which (elements of the) interventions could potentially be effective, and examine the barriers and facilitators to the acceptability, uptake and implementation of interventions designed to address FI in people with dementia who are resident in care homes. Methods and analysis: A realist synthesis approach to review the evidence will be used which will include studies on continence, person-centred care, implementation research in care homes, workforce and research on care home culture. An iterative four-stage approach is planned. Phase 1: development of an initial programme theory or theories that will be ‘tested’ through a first scoping of the literature and consultation with five stakeholder groups (care home providers, user representatives, academics and practice educators, clinicians with a special interest in FI and continence specialists). Phase 2: a systematic search and analysis of published and unpublished evidence to test and develop the programme theories identified in phase 1. Phase 3: validation of programme theory/ies with a purposive sample of participants from phase 1. Ethics and dissemination: The overall protocol does not require ethical review. The University research ethics committee will review interviews conducted as part of phase 1 and 3. The final fourth phase will synthesise and develop recommendations for practice and develop testable hypotheses for further research.

Introduction Faecal incontinence (FI) is the involuntary loss of liquid or solid stool that is a social or hygienic problem. The prevalence of FI in residents of care homes is high, but it is not an inevitable consequence of old age or dementia. There is good evidence on risk factors, but few studies provide evidence about effective interventions. There is a need to understand how, why, and in what circumstances particular programmes to reduce and manage FI are effective (or not) for people with dementia. The purpose of this review is to identify which (elements of the) interventions could potentially be effective, and examine the barriers and facilitators to the acceptability, uptake and implementation of interventions designed to address FI in people with dementia who are resident in care homes. Methods and analysis A realist synthesis approach to review the evidence will be used which will include studies on continence, person-centred care, implementation research in care homes, workforce and research on care home culture. An iterative four-stage approach is planned. Phase 1: development of an initial programme theory or theories that will be ‘tested’ through a first scoping of the literature and consultation with five stakeholder groups (care home providers, user representatives, academics and practice educators, clinicians with a special interest in FI and continence specialists). Phase 2: a systematic search and analysis of published and unpublished evidence to test and develop the programme theories identified in phase 1. Phase 3: validation of programme theory/ies with a purposive sample of participants from phase 1. Ethics and dissemination The overall protocol does not require ethical review. The University research ethics committee will review interviews conducted as part of phase 1 and 3. The final fourth phase will synthesise and develop recommendations for practice and develop testable hypotheses for further research.

This commentary considers the potential role of patient and public involvement in implementation. Developing an analytical thread from the resource-based view of the Firm, we argue that this involvement may create unique resources that have the capacity to enhance the impact of implementation activity for healthcare organisations.

Background: Reducing the rates of healthcare acquired infections require efforts that focus on changing professional behaviour as well as providing strategies for practice (Huis et al, 2011). The term intermediary has been used to refer to individuals “within the practice environment who can influence nurses toward specific goals” (Ferguson et al, 2004: 325). Aim: to evaluate the role of the intermediary in promoting best practice in infection prevention and control Methods: Realist evaluation (Pawson & Tilley, 1997) was used to elicit an explanation of the contexts in which, and mechanisms through which, intermediaries support infection prevention and control best practice. A realist synthesis of the literature was conducted, and mixed methods case studies were undertaken within two NHS hospitals in the United Kingdom, with data comprising of interviews, non-participant observations, and documentation review. Data were integrated and analysed to develop a refined set of findings that explained the intermediary’s role in promoting best practice. Stakeholders’ involvement throughout the study was important. Discussion: Findings showed that intermediary proximity and presence in clinical areas is important, and together with ways in which intermediaries ‘watch over’ practice, can promote better adherence to infection control practice. Intermediaries’ styles and approaches are influential, and can lead to clinical staff feeling individually supported. Policy discourse and enforcement, and the ways in which intermediaries provide feedback contribute to promoting good habitual behaviours. Conclusion: The findings of this study are informative for both policy and practice because they identify factors that could be built into future intermediary programmes. Fundamentally, organisational commitment to invest in programmes that are clinically embedded and which support the development of individuals who have the potential to influence practice is warranted.

There was a big financial investment in setting up nine partnerships between higher education institutions and health-care organisations. The partnerships were called Collaborations for Leadership in Applied Health Research and Care (CLAHRCs). The idea behind them is that, if those who produce research were closer to those who use it, more relevant research would be conducted and this research would be more likely to be used in practice. This study looked at how CLAHRCs were facilitating the use of research in practice. We studied three CLAHRCs by interviewing people, observing events and looking at their documents over 54 months. We found that their opportunities to implement research in practice were influenced by the vision and views of those who set them up, including how they had structured the CLAHRCs. CLAHRC leaders played an important role in how the collaboration functioned. Researchers and practitioners had different views about what a CLAHRC was for and therefore ‘what was in it for them’ if they got involved. People had been employed to cross the boundary between practice and higher education and in some contexts they had been successful in facilitating knowledge sharing and exchange. There were examples of CLAHRC activity having an impact on the way that services were delivered to patients, and in providing opportunities for practitioners and researchers to come together to share ideas and do joint projects. A CLAHRC approach shows promise, but more time and development will be needed to realise their full potential in increasing the use of research in practice.

Purpose: The purpose of this presentation is to share the findings from a research study funded by the National Institute for Health Research Services and Delivery Research Programme. Support workers make up the majority of the workforce in health and social care services for older people. There is evidence to suggest that support workers are not deployed as effectively as possible, are often undervalued, and there are gaps in understanding support worker roles across different care settings. The review was designed to answer the question: how can workforce development interventions improve the skills and the care standards of support workers within older people’s health and social care services? Design: The review was conducted in four iterative stages over 18 months:(1) development of a theoretical framework and initial programme theory; (2) retrieval, review and synthesise evidence relating to interventions designed to develop the support workforce guided by the programme theories; (3) ‘testing out’ the synthesis findings to refine the programme theories, and establish their practical relevance/potential for implementation, and (4) forming recommendations about how to improve current workforce development interventions to ensure high standards in the care of older people. Findings: Eight CMO configurations emerged from the review process, which provide a programme theory about ‘what works’ in developing the older person’s support workforce. The findings indicate that the design and delivery of workforce development should consider and include a number of starting points, specifically; personal factors about the support worker; the specific requirements of workforce development, and the fit with broader organisational strategy and goals. Conclusions: The review has resulted in an explanatory account of how the design and delivery of workforce development interventions work to improve the skills and care standards of support workers within older people’s health and

In this commentary the findings from a systematic review that concluded there is no compelling evidence to suggest that implementing complicated, multi-faceted interventions is more effective than simple, single component interventions to changing healthcare professional’s behaviour are considered through the lens of Harvey and Kitson’s editorial. Whilst an appealing conclusion, it is one that hides a myriad of complexities. These include issues concerning how best to tailor interventions and how best to evaluate such efforts. These are complex issues that do not have simple solutions.

In recent years, there have been calls for researchers to consider different approaches to managing the complexity that is inherent within health systems (Marchal et al, 2012). Using complexity theory, reality can be understood as “comprising multiple nested open systems in which change is generative, context-dependent and time irreversible” (Westhrop, 2012: 406). In health and social science research, the choice of methodology for student projects is important as emphasis is increasingly placed on what works and why in different contexts, rather than a preoccupation with finding out if interventions work. Concern has been expressed about the fit of traditional paradigm-based approaches to examining complex social programmes/interventions. For example, the appropriateness of the RCT in open systems has been questioned (Porter & O’Halloran, 2011), and a constructivist enquiry might miss “structural and institutional features of society which are in some respects independent of the individuals’ reasoning and desires” (Pawson & Tilley: 1997: 23). We will present a themed paper to provide a debate about choosing realist methodology for student projects, and provide a reflective account of our own journeys. Using short film clips, we will introduce the thought processes that represent our early experiences and the trail that led us to embrace the realist methodology. In between the short film clips we will present perspectives around switching points that lead to methodological decision-making, these include: • Individual background/perspectives • Complexity of topic areas • Traditional researcher teaching • Supervisors and supervision process • Research purpose In conclusion, this paper should trigger discussion about the phases that concern current students and consider types of support that are available when using realist methodologies.

This poster is a report of part of findings from an original research study in the area of realist evaluation which was designed to evaluate the role of the ‘intermediary’ in promoting best practice in infection prevention and control. In healthcare, intermediary roles have potential to support the translation of evidence into everyday practice (Chew et al, 2013), especially through the ways in which they act to “bridge the communities of research and clinical practice” (Milner et al, 2005: 900). However, understanding the effectiveness of intermediary interventions is challenging, given the complexity of the processes involved and the context-dependent, contingent nature of their work (Chew et al, 2013: 337). Study aim and objectives: The aim of the study was to seek the programme theories to show how intermediaries promote best practice in infection prevention and control; to determine what works, for whom, how, and in what respects. Methods: Realist evaluation was used to elicit a better understanding of the mechanisms and contexts that lead to outcomes (CMOs) for the role of intermediaries in infection prevention and control programmes. An essential element which separates realist evaluations from other types of outcome-focused evaluations is the focus on understanding how programmes or services, which offer different resources, have different effects for people (Timmins & Miller, 2007). In this study, a realist review led to case studies conducted consecutively within two NHS hospitals in the United Kingdom, with data comprising of interviews, non-participant observations, and documentation review. Findings: In infection control practice, intermediaries discussed “watching over” as an inherent part of their role. To consider the implication for future policy and practice, this finding was explored through a Foucaldian lens, to understand how surveillance of people who operate in organisations and institutions (such as hospitals), is historically drawn from know

Rationale, aims and objectives This paper addresses the challenge of investigating fidelity in the implementation of a complex rehabilitation intervention designed to increase the level of independence in personal activities of daily living of stroke patients living in UK care homes. A programme theory of intervention fidelity was constructed to underpin a process evaluation running alongside a cluster randomized trial of the rehabilitation intervention. Methods The programme theory has been constructed drawing on principles of realist evaluation. Using data from in-depth semi-structured interviews (n = 17) with all occupational therapists (OTs) and critical incident reports from the trial (n = 20), and drawing from frameworks for implementation, the programme theory was developed. Results The programme theory incorporates four potential mechanisms through which fidelity within the trial can be investigated. These four programme theory areas are (1) the balancing of research and professional requirements that therapists performed in a number of areas while delivering the study interventions; (2) the OTs rapport building with care home staff; (3) the work focused on re-engineering the personal environments of care home patients; and (4) the learning about the intervention within the context of the trial and its impacts over time. Conclusions These findings characterize the real-world nature of fidelity within intervention research, and specifically the negotiated nature of implementation within clinical settings, including individual patients' needs. This research adds to the evidence base because current frameworks for fidelity neglect the importance of learning over time of individuals and across the time span of a trial.

Background Mindfulness-based cognitive therapy (MBCT) is a cost-effective psychosocial prevention programme that helps people with recurrent depression stay well in the long term. It was singled out in the 2009 National Institute for Health and Clinical Excellence (NICE) Depression Guideline as a key priority for implementation. Despite good evidence and guideline recommendations, its roll-out and accessibility across the UK appears to be limited and inequitably distributed. The study aims to describe the current state of MBCT accessibility and implementation across the UK, develop an explanatory framework of what is hindering and facilitating its progress in different areas, and develop an Implementation Plan and related resources to promote better and more equitable availability and use of MBCT within the UK National Health Service. Methods/Design This project is a two-phase qualitative, exploratory and explanatory research study, using an interview survey and in-depth case studies theoretically underpinned by the Promoting Action on Implementation in Health Services (PARIHS) framework. Interviews will be conducted with stakeholders involved in commissioning, managing and implementing MBCT services in each of the four UK countries, and will include areas where MBCT services are being implemented successfully and where implementation is not working well. In-depth case studies will be undertaken on a range of MBCT services to develop a detailed understanding of the barriers and facilitators to implementation. Guided by the study’s conceptual framework, data will be synthesized across Phase 1 and Phase 2 to develop a fit for purpose implementation plan. Discussion Promoting the uptake of evidence-based treatments into routine practice and understanding what influences these processes has the potential to support the adoption and spread of nationally recommended interventions like MBCT. This study could inform a larger scale implementation trial and feed into future i