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The Alberta Context Tool (ACT)

The Alberta Context Tool (ACT). Carole A. Estabrooks Professor & Canada Research Chair Janet Squires Doctoral candidate Faculty of Nursing University of Alberta KU09 Wales, UK June 24-26, 2009. ACT overview. 59 items representing 8 modifiable dimensions of context Currently

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The Alberta Context Tool (ACT)

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  1. The Alberta Context Tool (ACT) Carole A. Estabrooks Professor & Canada Research Chair Janet Squires Doctoral candidate Faculty of Nursing University of Alberta KU09 Wales, UK June 24-26, 2009

  2. ACT overview 59 items representing 8 modifiable dimensions of context Currently 3 versions Adults (acute care) Pediatrics (acute care) Long term care 6 groups Healthcare Aides (LTC only) Nurses Allied Physicians Specialists/Educators Managers

  3. Initial ACT development Selection of a conceptual framework Critical review of literature Promoting Action on Research Implementation in Health Services (PARiHS) framework as initial guide Conceptual refinement Addition of concepts to incorporate team’s understanding of other relevant aspects of organizational context Conceptual and operational definitions developed

  4. Initial development Survey construction Item construction Initially versions for 5 groups in adult acute care (RN/LPN, MD, Allied, Managers, Educators) Feasibility modifications Survey administration and debriefing sessions were held with members of the five groups (summer, 2006) Modifications made based on debriefing feedback Question clarity Revision of examples Length/respondent burden Response process validity evidence

  5. Framework PARiHS Framework Research implementation Leadership Adding to context Context + • Slack • Interactions • Resources • Social capital Culture Facilitation Evaluation Evidence • Attitude • PSA • Belief suspension • MBI • SF-8 Individual attributes Kitson, et al., 1998, QSHC Rycroft-Malone et al, 2002 (J Adv Nurs)

  6. ACT Framework Leadership Adding to context Context • Organizational slack • Formal interactions • Informal interactions • Structural & electronic resources • Social capital Culture Evaluation

  7. Structure of ACT • 1. Leadership • 6 items scored on a 5-point Likert like scale • Concepts reflected in items: openness, optimism, self control,  empathic, developing  others, conflict management  • e.g., The leader calmly handles stressful situations • 2. Culture • 6 items scored on a 5-point Likert like scale • Concepts reflected in items: recognition, autonomy, worklife balance, development opportunity, focus on service/mission, support  • e.g., I receive recognition from others about my work • 3. Evaluation • 6 items scored on a 5-point Likert like scale • Concepts reflected in items: data access, informal data review, formal data review, action planning, performance monitoring,  benchmarking • e.g., Our team routinely discusses this data informally

  8. Structure of ACT • 4. Formal Interactions • 5 items scored on a 5-point frequency scale • Concept reflected in items: Interactions with others through engagement in formal organizational (unit) activities • e.g., Team meetings about residents • 5. Informal Interactions • 6-9 items scored on a 5-point frequency scale • Concept reflected in items: Interactions with others through engagement in informal organizational (unit) activities • e.g., Other professionals in my discipline • 6. Social Capital • 6 items scored on a 5-point Likert like scale • Concepts reflected in items: bonding, bridging, linking • e.g., People in my group share information with others in the group

  9. Structure of ACT • 7. Structural and Electronic Resources • Structural: 9 items scored on a 5-point frequency scale • Electronic: 3 items scored on a 5-point frequency scale • Concept reflected in items: availability/use of structural and  electronic resources • e.g., Policy and procedure manuals  • 8. Organizational Slack • 9-11 items consisting of 3 sub-scales • Staffing (2-3 items scored on a 5-point Likert like scale assessing availability of adequate staffing resources • Space (3-4 items scored on Likert and frequency scales assessing availability and use of space • Time (4 items scored on a 5-point frequency scale assessing availability and use of time) • e.g., Have time to do something extra for residents

  10. Validation

  11. The Standards1 approach to validity A unitary approach to validity assessment where empirical results are classified as supporting (or refuting) validity 1Standards for Educational and Psychological Testing. AERA; 1999.

  12. Initial validation (AKUTE1 study) • Acute Care (Adult) setting • 4 teaching hospitals in Alberta • 5 professional provider groups (N=453) • Reliability (alpha) • Range: .65 (formal interactions) to .92 (evaluation) • All but one >.70 • Validity (internal structure evidence) • Factor analysis (PCA with Varimax rotation) • 14 factor solution; 67% of the variance • ACT core (culture, leadership, evaluation – 31.95% of variance) 1`AKUTE: Estabrooks, Norton, Birdsell, Cummings, Newton. AHFMR funded

  13. Second validation study (pilot + wave 1 CIHR Team in Children’s Pain) • Survey revisions made based on pilot findings from four pediatric acute care units in Alberta (response process) • Validation study - acute care (pediatric) setting • 8 pediatric hospitals across Canada • 5 professional provider groups (N=1248) • Validation with Nurses (N=850) • Reliability (alpha) • Range: .60 (formal interactions) to .91 (evaluation) • All >.70 except for formal interactions (.60) and space (.65)

  14. Second validation study • Validity (internal structure evidence) • Item assessment • Item-total statistics remained stable • Factor analysis • 14 factor solution; 61% of the variance • ACT core (culture, leadership, evaluation – 27.63%) • Some realignment of items (formal/informal interactions)

  15. Second validation study • Validity (relationship with other variables evidence) • Correlation analysis • All ACT dimensions significantly correlated with IRU • Range: r=.052 (OS-staff) to .272 (structural/electronic resources) • Regression Analysis • 7/8 ACT dimensions predict research use (at hospital level) at p<.10 (exception: structural/electronic resources)

  16. Additional Validation(CapitalCare studuy) Pilot Study • 91 LPNs and HCAs in 4 long-term care units • Extensive feasibility testing (response process validity evidence) • Reliability: • Alpha > .70 for 7/8 dimensions (formal interactions revised) • Alpha range 0.50 (formal interactions) to 0.96 (evaluation)

  17. Ongoing plans • The ACT currently under revision • i.e., harmonize across versions , reduce the number of versions • Planned validation: • Psychometric assessment in new populations and in settings: • Further psychometric assessment: • Item Response Theory (IRT) • Confirmatory Factor Analysis (CFA) • Ongoing work re scoring of dimensions • Assessment of translated versions (e.g., Swedish, French)

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