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A qualitative study of a primary-care based intervention to improve the management of patients with heart failure: the dynamic relationship between facilitation and context.

Tierney S, Kislov R, Deaton C - BMC Fam Pract (2014)

Bottom Line: While contextual challenges associated with improvement in primary care have been documented previously, we still know relatively little about how the intentional, theory-informed facilitation of evidence-based change is shaped by contextual factors within this healthcare setting.At the same time, we argue that contextual factors, such as top-level endorsement, the necessity to comply with a performance measurement system, and the varying involvement of practice nurses produce tensions that can have both an enabling and constraining effect on the process of facilitation.Those involved in facilitating change within primary care have to manage tensions arising from the interplay of these different contextual forces to minimise their impact on efforts to alter practice based on best evidence.

View Article: PubMed Central - PubMed

Affiliation: Royal College of Nursing Research Institute, University of Warwick, Coventry, UK. sjftierney@yahoo.co.uk.

ABSTRACT

Background: There is currently a growing emphasis in primary care on upscaling the provision of evidence-based services for specific conditions, such as heart failure (HF), which have traditionally been seen as part of a specialist's domain. While contextual challenges associated with improvement in primary care have been documented previously, we still know relatively little about how the intentional, theory-informed facilitation of evidence-based change is shaped by contextual factors within this healthcare setting. Hence, a qualitative study was conducted to address the question: How is the process of facilitating evidence-based practice affected by the context of primary care?

Methods: Data collection took place across general practices in northwest England as part of a process evaluation of the Greater Manchester HF Investigation Tool (GM-HFIT) - a programme of work aiming to improve the management of HF in primary care. Semi-structured interviews, with purposefully selected GM-HFIT team members (n = 9) and primary care practitioners (n = 7), were supplemented by observational data and a three-month diary reflecting on facilitation activities. Framework analysis was used to manage and interpret data.

Results: We describe a complex and dynamic interplay between facilitation and context, focusing on three major themes: (1) Addressing macro and micro agendas; (2) Forming a facilitative unit; (3) Maintaining momentum. We show that HF specialist nurses (HFSNs) have a high level of professional credibility, which allows them to play a key role in making recommendations to practices for improving patient care. At the same time, we argue that contextual factors, such as top-level endorsement, the necessity to comply with a performance measurement system, and the varying involvement of practice nurses produce tensions that can have both an enabling and constraining effect on the process of facilitation.

Conclusions: When facilitating the transfer of evidence, context is an important aspect to consider at a macro and micro level; a complex interplay can exist between these levels, which may constrain or enable efforts to amend practice. Those involved in facilitating change within primary care have to manage tensions arising from the interplay of these different contextual forces to minimise their impact on efforts to alter practice based on best evidence.

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Related in: MedlinePlus

Shows how macro and micro contextual factors contributed to tensions associated with facilitation in GM-HFIT(key: rectangle with full line = macro context; rectangle with dashed line = micro context; shaded hexagon = project tensions).
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Fig1: Shows how macro and micro contextual factors contributed to tensions associated with facilitation in GM-HFIT(key: rectangle with full line = macro context; rectangle with dashed line = micro context; shaded hexagon = project tensions).

Mentions: Our data reflect and extend aspects present within the PARiHS framework. For example, findings highlight the complex and dynamic nature of changing practice. We found that even if individuals were receptive to new evidence, they may not carry out work required for a project like GM-HFIT due to organisational pressures and barriers, such as lack of time, which has been noted in other studies [12]. Facilitating change was shaped by contextual factors and could result in some tensions. For example, endorsement of GM-HFIT from regional bodies assisted with recruitment of practices but placed a demand on resources. Likewise, how practices were encouraged to participate (some only doing so due to such promotion from an influential organisation) could lead to misunderstanding about GM-HFIT’s aims. Hence, findings emphasise contextual tensions that are present when trying to facilitate change in healthcare settings (Figure 1). Tensions differ from barriers described by others [14]. They are more rounded, with positive and negative components; they are less black or white than a barrier, emphasising relationships between stakeholders and the interplay between different contextual levels. Part of the role of facilitation appeared to be negotiating these tensions so they did not impede the project’s progression. Data suggest that responsibility for continuing the work was not always accepted by primary care staff because of the mixture of internal and external tensions (Figure 1). For example, national targets influenced what activities were accepted and adopted within a surgery. Similarly, tensions could emerge if individuals were unclear why the work was necessary. As a consequence, some team members may be less accommodating to change (e.g. delay following up queries from the audit).Figure 1


A qualitative study of a primary-care based intervention to improve the management of patients with heart failure: the dynamic relationship between facilitation and context.

Tierney S, Kislov R, Deaton C - BMC Fam Pract (2014)

Shows how macro and micro contextual factors contributed to tensions associated with facilitation in GM-HFIT(key: rectangle with full line = macro context; rectangle with dashed line = micro context; shaded hexagon = project tensions).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4263017&req=5

Fig1: Shows how macro and micro contextual factors contributed to tensions associated with facilitation in GM-HFIT(key: rectangle with full line = macro context; rectangle with dashed line = micro context; shaded hexagon = project tensions).
Mentions: Our data reflect and extend aspects present within the PARiHS framework. For example, findings highlight the complex and dynamic nature of changing practice. We found that even if individuals were receptive to new evidence, they may not carry out work required for a project like GM-HFIT due to organisational pressures and barriers, such as lack of time, which has been noted in other studies [12]. Facilitating change was shaped by contextual factors and could result in some tensions. For example, endorsement of GM-HFIT from regional bodies assisted with recruitment of practices but placed a demand on resources. Likewise, how practices were encouraged to participate (some only doing so due to such promotion from an influential organisation) could lead to misunderstanding about GM-HFIT’s aims. Hence, findings emphasise contextual tensions that are present when trying to facilitate change in healthcare settings (Figure 1). Tensions differ from barriers described by others [14]. They are more rounded, with positive and negative components; they are less black or white than a barrier, emphasising relationships between stakeholders and the interplay between different contextual levels. Part of the role of facilitation appeared to be negotiating these tensions so they did not impede the project’s progression. Data suggest that responsibility for continuing the work was not always accepted by primary care staff because of the mixture of internal and external tensions (Figure 1). For example, national targets influenced what activities were accepted and adopted within a surgery. Similarly, tensions could emerge if individuals were unclear why the work was necessary. As a consequence, some team members may be less accommodating to change (e.g. delay following up queries from the audit).Figure 1

Bottom Line: While contextual challenges associated with improvement in primary care have been documented previously, we still know relatively little about how the intentional, theory-informed facilitation of evidence-based change is shaped by contextual factors within this healthcare setting.At the same time, we argue that contextual factors, such as top-level endorsement, the necessity to comply with a performance measurement system, and the varying involvement of practice nurses produce tensions that can have both an enabling and constraining effect on the process of facilitation.Those involved in facilitating change within primary care have to manage tensions arising from the interplay of these different contextual forces to minimise their impact on efforts to alter practice based on best evidence.

View Article: PubMed Central - PubMed

Affiliation: Royal College of Nursing Research Institute, University of Warwick, Coventry, UK. sjftierney@yahoo.co.uk.

ABSTRACT

Background: There is currently a growing emphasis in primary care on upscaling the provision of evidence-based services for specific conditions, such as heart failure (HF), which have traditionally been seen as part of a specialist's domain. While contextual challenges associated with improvement in primary care have been documented previously, we still know relatively little about how the intentional, theory-informed facilitation of evidence-based change is shaped by contextual factors within this healthcare setting. Hence, a qualitative study was conducted to address the question: How is the process of facilitating evidence-based practice affected by the context of primary care?

Methods: Data collection took place across general practices in northwest England as part of a process evaluation of the Greater Manchester HF Investigation Tool (GM-HFIT) - a programme of work aiming to improve the management of HF in primary care. Semi-structured interviews, with purposefully selected GM-HFIT team members (n = 9) and primary care practitioners (n = 7), were supplemented by observational data and a three-month diary reflecting on facilitation activities. Framework analysis was used to manage and interpret data.

Results: We describe a complex and dynamic interplay between facilitation and context, focusing on three major themes: (1) Addressing macro and micro agendas; (2) Forming a facilitative unit; (3) Maintaining momentum. We show that HF specialist nurses (HFSNs) have a high level of professional credibility, which allows them to play a key role in making recommendations to practices for improving patient care. At the same time, we argue that contextual factors, such as top-level endorsement, the necessity to comply with a performance measurement system, and the varying involvement of practice nurses produce tensions that can have both an enabling and constraining effect on the process of facilitation.

Conclusions: When facilitating the transfer of evidence, context is an important aspect to consider at a macro and micro level; a complex interplay can exist between these levels, which may constrain or enable efforts to amend practice. Those involved in facilitating change within primary care have to manage tensions arising from the interplay of these different contextual forces to minimise their impact on efforts to alter practice based on best evidence.

Show MeSH
Related in: MedlinePlus