Determining the effectiveness of facilitation in developing practice with older people
Randal ParlourPhD Student University of Ulster
The Intent of Emancipation!
Study OverviewAimTo determine the effectiveness of facilitation strategies in the implementation of evidence into practice.
ObjectivesUndertake 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 indicateslittle 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 RealismEmancipatory Practice DevelopmentRealist EvaluationPARiHS (dimensions of Evidence, Context & Facilitation)
Macro ContextRaising consciousness of practice culture, leadership & evaluation
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 SetsPD WorkshopsTeamwork (High challenge, High support) Titchen 2001Clinical Support (group-based & one-to-one)Teaching Sessions
Evaluation of Practice Development ActivitiesOngoing Data Collection &AnalysisEVIDENCE(Continence benchmark)
Enlightenment Empowerment Emancipation
Culture of effectivePerson-centred care
CRARUM (Kontos & Poland 2009)
Practice development projects should be able to demonstrate the use of some or all of the following methods:
Agreed ethical processesStakeholder analysis and agreed ways of engaging stakeholdersPerson-centrednessValues clarificationDeveloping a shared visionWorkplace culture analysisCollaboration and participationDeveloping shared ownershipReflective learning
Methods to facilitate critical reflection (e.g. action learning)High challenge and high support FeedbackKnowledge use Process and outcome evaluationFacilitation of transitionsGiving space for ideas to flourishDissemination of learningRewarding success (McCormack et al 2006)
The Method Section as Conceptual EpicenterDeciding 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 designMany 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 methodDespite 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 may or may not be activated depending on context.
Thusin 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 resultIt is a theoretical base that informs the choice & development of study interventions as well as the interpretation of study resultsFor 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.
MethodologyManley & McCormack (2004) articulate an emancipatory model of PD defined by:
Participatory, collaborative and inclusive approaches to research and developmentWorking with values beliefs and assumptions Enablement strategiesFacilitationSystematic, 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 careEPD 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 timeThis 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 happeningThe 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 & experiencesThe outcome is to describe the existing or non-existing relationship between the 3
Evaluation: Guided by principles of Realist EvaluationComplements 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 evaluationEnables the review of the evidence base underpinning practice developmentsEnables 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
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 lead