Transcript Slide 1

“Determining the
effectiveness of facilitation
in developing
practice with older people”
Randal Parlour
PhD Student
University of Ulster
The Intent of Emancipation!
Study Overview
Aim
 To determine the
effectiveness of
facilitation strategies
in the implementation
of evidence into
practice.
Objectives
1.
2.
3.
4.
Undertake a review of the theory and practice of
facilitation in order to describe the differing models
and approaches used. Extend this to methods of
evaluation of facilitation.
Identify a menu of facilitation strategies that can be
offered to participating sites. Work with the
participating sites to establish a facilitation
framework focusing on the implementation of the
Essence of Care ‘Continence’ Benchmark
standards.
Describe the participants and facilitator
experiences of engaging in facilitation (process
data)
To gather appropriate outcome data, before and
after implementation of facilitation strategies.
Rationale – current literature
indicates

little evidence currently exists about the meaning of
facilitation, the role of facilitators and the
effectiveness of differing models in order to achieve
practice cultures that are evidence-based and
person-centred (Greenhalgh et al, 2004)

Need to increase understanding of what practice
developers mean by facilitation, to explicate how
practice developers facilitate change in practice, and
to elucidate how the recipients of facilitation describe
this experience (McCormack et al, 2006; Larsen et al, 2005; Simmons, 2004)


mechanisms for facilitation are rarely evaluated with
regard to implementation outcomes (Fixsen et al, 2005)
Despite a growing awareness that getting evidence into
practice is a complex, multi-faceted process, there
remains a lack of knowledge about what methods and
approaches are effective, with whom and in what
contexts (Kitson et al, 2008)
Additional research is required, therefore, to establish a
rationale for particular facilitation or implementation
interventions within the practice environment
Methodological Influences:




Critical Realism
Emancipatory Practice Development
Realist Evaluation
PARiHS (dimensions of Evidence, Context
& Facilitation)
CONCEPTUAL FRAMEWORK
Enlightenment
Empowerment
Emancipation
Macro Context
Raising
consciousness of
practice culture,
leadership &
evaluation
Mid-range
theories about
context,
facilitation and
identification
of facilitation
options relating
to the context
of
participating
site
Micro Context
EVIDENCE
(Continence benchmark)
Implementation of
benchmark using 1
of 5 facilitation
options:
Action Learning
Sets
PD Workshops
Teamwork (High
challenge, High
support) Titchen
2001
Clinical Support
(group-based &
one-to-one)
Teaching Sessions
Evaluation of
Practice
Development
Activities
Ongoing Data
Collection &
Analysis
Outcome:
Culture
of
effective
Personcentred
care
CRARUM
(Kontos & Poland 2009)
Practice development projects should be able to
demonstrate the use of some or all of the following
methods:
1. Agreed ethical processes
2. Stakeholder analysis and
agreed ways of engaging
stakeholders
3. Person-centredness
4. Values clarification
5. Developing a shared vision
6. Workplace culture analysis
7. Collaboration and
participation
8. Developing shared
ownership
9. Reflective learning
10. Methods to facilitate
critical reflection (e.g.
action learning)
11. High challenge and high
support
12. Feedback
13. Knowledge use
14. Process and outcome
evaluation
15. Facilitation of transitions
16. Giving space for ideas to
flourish
17. Dissemination of learning
18. Rewarding success
(McCormack et al 2006)
The Method Section as Conceptual
Epicenter

Deciding on the appropriateness of a chosen
methodology & its philosophical underpinnings is an
essential component of rigour in research design
(Appleton & King 2002)



The philosophical groundwork must be undertaken
before the ‘doing’ phase of the research (Trigg 2001)
Nurse researchers do not always pay sufficient heed to
the philosophic and theoretic elements of research
design
Many nursing research reports lack argumentative
coherence & validity (Lipscomb 2008)

Emphasising the importance of argumentative
structure may appear needlessly abstract to
researchers who are grappling with complex real
world issues
(Foss & Ellefsen 2002)

Method sections in social science research
reports often lack sufficient detail to make any
results that follow from the analytic method
trustworthy
(Smagorinsky 2008)


Explicitly stated research questions need
to be answerable through the methods
employed in the research & results need
to be specifically linked to method
Despite notable consensus that the use of
theory is crucial in the design & evaluation
of implementation research (Kitson et al 2008) it is
rarely & ineffectively used (Eccles et al 2005)


To provide rigour when preparing a research
design, the researcher needs to carefully
consider not only the methodology but also the
philosophical intent of the study (Wilson & McCormack 2006)
Thus participatory action research is
inappropriate if the knowledge sought is merely
shared views, without opportunity to engage in
action to address domination & power inequities.
Critical Realism (CR)

CR is a philosophical approach pivotal to which
exists the ontological claim that there is a
dimension of reality that surpasses observable
phenomena, independent of individual perception
that includes core generative mechanisms that m
or may not be activated depending on context.
Thus…in this study


CR is a perspective that can illuminate mechanisms
embedded in clinical settings & interventions and
facilitate undrstanding of the outcomes that may or may
not result
It is a theoretical base that informs the choice &
development of study interventions as well as the
interpretation of study results
For critical realists explanatory power derives not from
counting the co-presence of observable phenomena and
inferring causation from empirical co-occurrence, but
from identifying causal mechanisms, how they work, &
discovering if they have been activated and under what
conditions
(Kontos & Poland, 2009)
Critical Realism:
The integration of CR in health care
research can




Address the complexities of practice as a
meaning-making activity;
Optimise interventions for local circumstances;
Target crucial factors in the organisational
context that influence behaviour;
Disseminate evidence in a way that engages
practitioners in critical thought;
Facilitate the achievement of best practice.
Methodology
Manley & McCormack (2004) articulate an
‘emancipatory’ model of PD defined by:





Participatory, collaborative and inclusive
approaches to research and development
Working with values beliefs and assumptions
Enablement strategies
Facilitation
Systematic, rigorous and
continuous processes of
emancipatory change
Emancipatory Practice
Development (EPD)


The intent of EPD is to
increase effectiveness in
patient-centred care through
enabling of healthcare teams
to transform the culture &
context of care
EPD is characteristic of
the 3 phases which underpin
Critical Social Science –
consciousness raising,
becoming motivated to take
action, & finally taking action
Critical Realist Evaluation (RE)


Proponents of RE (Pawson 2002; Wilson & McCormack 2006) argue
that the central question is not whether certain
interventions work in a generalisable way, but
what will work with these ‘actors’ in this setting
at this time
This enables understanding of relationships
between the innovation & structural & agential
properties that inform uptake, need for
refinement, & factors important for replication



Realist Evaluation offers researchers a more
complete picture of what is happening with EPD
programmes and why it is happening
The Context, mechanism, outcome formula is
based on the principles of realism – real
(mechanisms); actual (events which may or may
not be observed); empirical (evidence of
observable events & experiences
The outcome is to describe the existing or nonexisting relationship between the 3
Evaluation: Guided by principles
of Realist Evaluation



Complements EPD (distinguishes when
context and facilitation may exert
influence)
Evaluates the relationship between
context, mechanism and outcome (thus
the mechanism employed ‘makes sense
of’ the specific outcome pattern observed)
Informs the transferability of EPD
processes into differing contexts (Wilson &
McCormack, 2006)
Manley & McCormack (2004) argue that any
evaluation framework should answer 5
essential questions about interventions:





Whether it works?
Why it works?
For whom it works?
Under what circumstances it works?
What has been learnt to make it work?



Enables the adoption of a systematic
approach to developmental work and its
evaluation
Enables the review of the evidence base
underpinning practice developments
Enables PD consumers to make judicious
decisions about applicability within their
own particular context
(McCormack 2007)
Evaluation as hypothesis testing
(Pawson & Tilley 1997)
Context
Mechanism
Outcome
External & Internal requirements for
change
M1Action Learning
Increased experience in managing
complex change
C(1) Lack of shared sense of
purpose; lack of trust; practice not
questioned; traditional values; poor
sense of belonging
M1(A)Values clarification Exercise
M1(B)Leadership programme
facilitated using action learning
approach
O(1)Philosophical core values
established
O(2)Practitioners supported to
challenge practice; team members
valued; effective communication
systems
C (2)Aspirations for critical
dialogue; constructive feedback
from colleagues.
C(3)Evidence base for practice
unclear
M1(C) Reflective Practice
O(3)Custom & practice challenged
O(4)Clear continence criteria
identified
Expert knowledge clarified
O(5)Increased practitioner
confidence
C(4)Lack of formal systems for
receiving feedback
M1(D) 360 feedback
O(6)Increased confidence
Increased awareness of roles of
others
Increased competence within own
role
C(5)Lack of formal evaluation
processes to test compliance
with standards & benchmarks
M1(E) Clinical Audit
O(7)Evaluation culture
developed
Receptive practice development
culture.

Linkages between evidence, the context in which it is
implemented and the practice development processes
involved in facilitating its use in practice are considered
by referring to the (PARIHS) project

(Kitson et al, 1998)
Emancipatory practice development is coherent with the
PARIHS framework as both highlight the significance of
effective facilitation and transformational leadership in
achieving successful implementation.
Data Collection – first steps


Following the logic of critical realism,
qualitative & quantitative methods of data
collection can serve to identify causal
generative mechanisms of existing care
These reveal contradictions between
espoused & enacted practice, & existing
barriers to best practice
Data Collection
A number of quantitative & qualitative
instruments were employed:




Context Assessment Index – a tool to assess the practice context in which
continence care is managed
Observational Tool – The observational schedule was semi-structured and
developed from the EOC continence benchmark standard and Manley’s
cultural indicators (2000). This provided the focus for observation of ‘good
practice’.
Continence Audit – reviewed the provisions for good continence care
within the unit including facilities, access to continence aids, staff
education programmes etc.
Focus Group – this followed analysis of data previously collected & was
used to gain views on the context of continence practice within the unit, &
insight into observational data collected.
Provides differing sources of evidence; creates a more meaningful and deeper understanding of the changing
context; and enhances validity and credibility of findings.
Findings – Phase 1 Stage 1



The findings from the context assessment index (CAI)
indicated the presence of an extremely strong and
positive practice context within the unit prior to the
introduction of facilitation interventions.
The observational study which was undertaken at this
time and identified specific cultural indicators which
supported the presence of a strong practice culture.
The unit scored highly when audited against the criteria
for continence, bladder & bowel care within the Essence
of care continence benchmarks. The results
demonstrated a high overall compliance rate.
Group/Standard Scores f or
Context Assessment Index (CAI)
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
A
B
C
Group/Standard
B=Culture 77.08 C=Leadership
73.81
D=Evaluation 77.31
A
B
C
D
D
Group/Standard Scores f or
CAI 2
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
A
B
C
Group/Standard
B=Culture 60.16 C=Leadership
51.43
D=Evaluation 62.17
A
B
C
D
D
Cont…



The results of the focus group emphasised contradictions
within the initial findings and underlined tensions that
existed within the team.
The views expressed by participants, at this stage, were
inconsistent with some of the findings arising from the
CAI & observational exercise. This implied that there was
a difference between how the team wanted to work
together and the reality of practice.
Key issues initially emerged around the areas of insight
& consciousness of practice culture, shared purpose,
leadership, teamwork, evaluation processes, assessment
& planning of care
“… the transformation of practice
understands that changing
practices is not just a matter of
changing the ideas of individual
practitioners alone, but also
discovering, analysing and
transforming the social, cultural,
discursive and material conditions
under which their practice occurs
…”
(Kemmis, 2005)
Thank you for listening!
Randal Parlour
NMPDU
Iona House, Ballyshannon.
Co. Donegal
Ireland
[email protected]