Doctor of Philosophy
Sydney Business School
Masso, Malcolm, It’s the little things that matter: implementation of evidence-based practice in residential aged care, Doctor of Philosophy thesis, Sydney Business School, University of Wollongong, 2012. http://ro.uow.edu.au/theses/3645
This study aims to make a contribution to knowledge about how to implement evidence in residential aged care. The context for the study was the Encouraging Best Practice in Residential Aged Care Program, funded by the Australian Government to facilitate the implementation of evidence-based practice in residential aged care. The study drew on the experiences of those involved in the program to answer the question: what mechanisms influence the implementation of evidence-based practice in residential aged care and how do those mechanisms interact?
The methodology used grounded theory from a critical realist perspective, informed by a conceptual framework that differentiates between the context, process and content of change. People were purposively sampled and invited to participate in semi-structured interviews. Fifty-one people were interviewed, in 44 interviews, between September 2009 and November 2010. With three exceptions, all interviews were conducted in person. Participants had direct experience of implementation in 87 facilities, across nine areas of practice, in diverse locations. Sampling continued until data saturation was reached. Literature was used to inform all stages of the study. The quality of the research was assessed using four criteria for judging trustworthiness: credibility, transferability, dependability and confirmability.
Data analysis resulted in the identification of four mechanisms that accounted for the events that took place and the experiences of those events. The core category that provided the greatest understanding of the data was the mechanism On Common Ground. A series of factors – conversation, language, how care was framed, whether a proposed change ‘made sense’ and whether colleagues were alike or not alike in some way – were identified by participants as important elements of 'common ground'; all of these factors served to place, or not place, individuals On Common Ground.
Participants described learning as an essentially creative process, rather than simply the transmission of information from one person to another. At the core of creating knowledge was the mechanism Learning by Connecting, whereby people were able to connect new knowledge with existing practice and knowledge, think 'outside the square' to connect with additional knowledge and make connections between actions and outcomes.
The process of integrating new practices took place in facilities that were highly structured in terms of routines, technologies, documentation systems, accreditation, funding and staffing. Relatively simple changes took place within complex structures, providing care to residents with complex needs. As the study progressed it became apparent that it was less about implementation of evidence-based practice than about the broader question of how to implement practice change. The fact that a change in practice was evidence-based had little influence on implementation.
Participants described a situation where any new practice, whether evidence-based or not, had to compete with an existing set of constantly shifting priorities. Reconciling Competing Priorities was an ongoing mechanism whereby new practices either became part of routine care or did not. Even becoming part of routine care was no guarantee that a new practice would take place all the time – it always had to compete with other priorities.
The mechanism Exercising Agency had close links with Reconciling Competing Priorities, bridging the gap between agency and action. It was the human dimension of change, both individually and collectively, that made things happen. Individuals may have possessed the necessary skills and knowledge to effect a change in practice, they may have learnt all there was to know about a proposed change, and they may have been able to reconcile the priorities facing them on a particular day, but they could still choose whether to act or not.
The findings include many of the factors identified in the literature about how to change practices, but in a way that provides some explanatory power; this fits the definition of theory, albeit a tentative theory. Changes in practice did not result from a simple set of causal links. The various relationships between the four mechanisms were more subtle than that, and best described as 'patterns of association'.
This study's various findings are consistent with the findings from other research, but the way they fit together is novel and adds to current knowledge about how to improve practices in residential aged care. The mechanisms open up many possibilities for further research, both within residential aged care and in health care more generally.