Randal Parlour PhD Student University of Ulster

1. “Determining the effectiveness of facilitation in developing practice with older people” Randal Parlour PhD Student University of Ulster

2. The Intent of Emancipation!

3. Study Overview Aim • To determine the effectiveness of facilitation strategies in the implementation of evidence into practice.

4. Objectives • 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.

5. 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)

6. 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

7. Methodological Influences: • Critical Realism • Emancipatory Practice Development • Realist Evaluation • PARiHS (dimensions of Evidence, Context & Facilitation)

8. CONCEPTUAL FRAMEWORK Enlightenment Empowerment Emancipation Macro Context Mid-range theories about context, facilitation and identification of facilitation options relating to the context of participating site 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 Person-centred care Raising consciousness of practice culture, leadership & evaluation Micro Context EVIDENCE (Continence benchmark)

9. CRARUM(Kontos & Poland 2009)

10. Agreed ethical processes Stakeholder analysis and agreed ways of engaging stakeholders Person-centredness Values clarification Developing a shared vision Workplace culture analysis Collaboration and participation Developing shared ownership Reflective learning Methods to facilitate critical reflection (e.g. action learning) High challenge and high support Feedback Knowledge use Process and outcome evaluation Facilitation of transitions Giving space for ideas to flourish Dissemination of learning Rewarding success (McCormack et al 2006) Practice development projects should be able to demonstrate the use of some or all of the following methods:

11. 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)

12. 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)

13. 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)

14. 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.

15. 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 may or may not be activated depending on context.

16. 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)

17. 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.

18. MethodologyManley & 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

19. 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 Emancipatory Practice Development (EPD)

20. 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

21. 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 non-existing relationship between the 3

22. 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)

23. 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?

24. 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)

25. Evaluation as hypothesis testing (Pawson & Tilley 1997)

26. 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. Context Mechanism Outcome

27. 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.

28. 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

29. Data CollectionA 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.

30. 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.

31. B=Culture 77.08 C=Leadership 73.81 D=Evaluation 77.31

32. B=Culture 60.16 C=Leadership 51.43 D=Evaluation 62.17

33. 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

34. “… 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)

35. Thank you for listening! Randal Parlour NMPDU Iona House, Ballyshannon. Co. Donegal Ireland randal.parlour@hse.ie