““Determining the Determining the effectiveness of effectiveness of

facilitation in facilitation in developing developing

practice with older practice with older people”people”

Randal ParlourRandal Parlour

PhD StudentPhD Student

University of UlsterUniversity of Ulster

The Intent of Emancipation!

Study OverviewStudy Overview

AimAim To determine the To determine the

effectiveness of effectiveness of facilitation facilitation strategies in the strategies in the implementation of implementation of evidence into evidence into practice.practice.

ObjectivesObjectives

1.1. Undertake a review of the theory and practice Undertake a review of the theory and practice of facilitation in order to describe the differing of facilitation in order to describe the differing models and approaches used. Extend this to models and approaches used. Extend this to methods of evaluation of facilitation.methods of evaluation of facilitation.

2.2. Identify a menu of facilitation strategies that Identify a menu of facilitation strategies that can be offered to participating sites. Work with can be offered to participating sites. Work with the participating sites to establish a facilitation the participating sites to establish a facilitation framework focusing on the implementation of framework focusing on the implementation of the Essence of Care ‘Continence’ Benchmark the Essence of Care ‘Continence’ Benchmark standards.standards.

3.3. Describe the participants and facilitator Describe the participants and facilitator experiences of engaging in facilitation (process experiences of engaging in facilitation (process data)data)

4.4. To gather appropriate outcome data, before To gather appropriate outcome data, before and after implementation of facilitation and after implementation of facilitation strategies. strategies.

Rationale – current Rationale – current literature indicatesliterature indicates

little evidence currently exists about the little evidence currently exists about the meaning of facilitation, the role of facilitators meaning of facilitation, the role of facilitators and the effectiveness of differing models in and the effectiveness of differing models in order to achieve practice cultures that are order to achieve practice cultures that are evidence-based and person-centred evidence-based and person-centred (Greenhalgh et al, (Greenhalgh et al, 2004)2004)

Need to increase understanding of what Need to increase understanding of what practice developers mean by facilitation, to practice developers mean by facilitation, to explicate how practice developers facilitate explicate how practice developers facilitate change in practice, and to elucidate how the change in practice, and to elucidate how the recipients of facilitation describe this recipients of facilitation describe this experience experience (McCormack et al, 2006; Larsen et al, 2005; (McCormack et al, 2006; Larsen et al, 2005; Simmons, 2004)Simmons, 2004)

mechanisms for facilitation are rarely evaluated with mechanisms for facilitation are rarely evaluated with regard to implementation outcomesregard to implementation outcomes (Fixsen et al, 2005)(Fixsen et al, 2005)

Despite a growing awareness that getting evidence Despite a growing awareness that getting evidence into practice is a complex, multi-faceted process, into practice is a complex, multi-faceted process, there remains a lack of knowledge about what there remains a lack of knowledge about what methods and approaches are effective, with whom methods and approaches are effective, with whom and in what contexts and in what contexts (Kitson et al, 2008)(Kitson et al, 2008)

Additional research is required, therefore, to Additional research is required, therefore, to establish a rationale for particular facilitation or establish a rationale for particular facilitation or implementation interventions within the practice implementation interventions within the practice environmentenvironment

Methodological Influences:Methodological Influences:

Critical RealismCritical Realism Emancipatory Practice DevelopmentEmancipatory Practice Development Realist EvaluationRealist Evaluation PARiHS (dimensions of Evidence, PARiHS (dimensions of Evidence,

Context & Facilitation)Context & Facilitation)

Macro Context

Raising consciousness of practice culture, leadership & evaluation

Micro 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 SetsPD WorkshopsTeamwork (High challenge, High support) Titchen 2001Clinical Support (group-based & one-to-one)Teaching Sessions

Evaluation of Practice

Development Activities

Ongoing Data Collection &

Analysis

EVIDENCE(Continence benchmark)

CONCEPTUAL FRAMEWORK

Enlightenment Empowerment Emancipation

Outcome:

Culture of

effectivePerson-centred

care

CRARUMCRARUM (Kontos & Poland 2009)(Kontos & Poland 2009)

Practice development projects should be Practice development projects should be able to demonstrate the use of some or all able to demonstrate the use of some or all

of the following methods:of the following methods:

1.1. Agreed ethical processesAgreed ethical processes2.2. Stakeholder analysis and Stakeholder analysis and

agreed ways of engaging agreed ways of engaging stakeholdersstakeholders

3.3. Person-centrednessPerson-centredness4.4. Values clarificationValues clarification5.5. Developing a shared Developing a shared

visionvision6.6. Workplace culture Workplace culture

analysisanalysis7.7. Collaboration and Collaboration and

participationparticipation8.8. Developing shared Developing shared

ownershipownership9.9. Reflective learningReflective learning

10.10. Methods to facilitate Methods to facilitate critical reflection (e.g. critical reflection (e.g. action learning)action learning)

11.11. High challenge and high High challenge and high support support

12.12. FeedbackFeedback13.13. Knowledge use Knowledge use 14.14. Process and outcome Process and outcome

evaluationevaluation15.15. Facilitation of transitionsFacilitation of transitions16.16. Giving space for ideas to Giving space for ideas to

flourishflourish17.17. Dissemination of learningDissemination of learning18.18. Rewarding successRewarding success

(McCormack et al 2006)(McCormack et al 2006)

The Method Section as The Method Section as Conceptual EpicenterConceptual Epicenter

Deciding on the appropriateness of a chosen Deciding on the appropriateness of a chosen methodology & its philosophical underpinnings is an methodology & its philosophical underpinnings is an essential component of rigour in research design essential component of rigour in research design

(Appleton & King 2002)(Appleton & King 2002)

The philosophical groundwork must be undertaken The philosophical groundwork must be undertaken before the ‘doing’ phase of the research before the ‘doing’ phase of the research (Trigg 2001)(Trigg 2001)

Nurse researchers do not always pay sufficient heed Nurse researchers do not always pay sufficient heed to the philosophic and theoretic elements of to the philosophic and theoretic elements of research designresearch design

Many nursing research reports lack argumentative Many nursing research reports lack argumentative coherence & validity coherence & validity (Lipscomb 2008)(Lipscomb 2008)

Emphasising the importance of Emphasising the importance of argumentative structure may appear argumentative structure may appear needlessly abstract to researchers who are needlessly abstract to researchers who are grappling with complex real world issues grappling with complex real world issues

(Foss & Ellefsen 2002)(Foss & Ellefsen 2002)

Method sections in social science research Method sections in social science research reports often lack sufficient detail to make reports often lack sufficient detail to make any results that follow from the analytic any results that follow from the analytic method trustworthy method trustworthy

(Smagorinsky 2008)(Smagorinsky 2008)

Explicitly stated research questions need Explicitly stated research questions need to be answerable through the methods to be answerable through the methods employed in the research & results need employed in the research & results need to be specifically linked to methodto be specifically linked to method

Despite notable consensus that the use Despite notable consensus that the use of theory is crucial in the design & of theory is crucial in the design & evaluation of implementation research evaluation of implementation research (Kitson et al 2008)(Kitson et al 2008) it is rarely & ineffectively used it is rarely & ineffectively used (Eccles et al 2005)(Eccles et al 2005)

To provide rigour when preparing a research To provide rigour when preparing a research design, the researcher needs to carefully design, the researcher needs to carefully consider not only the methodology but also consider not only the methodology but also the philosophical intent of the study the philosophical intent of the study (Wilson & (Wilson & McCormack 2006)McCormack 2006)

Thus participatory action research is Thus participatory action research is inappropriate if the knowledge sought is inappropriate if the knowledge sought is merely shared views, without opportunity to merely shared views, without opportunity to engage in action to address domination & engage in action to address domination & power inequities. power inequities.

Critical Realism (CR)Critical Realism (CR)

CR is a philosophical approach pivotal to CR is a philosophical approach pivotal to which exists the ontological claim that there which exists the ontological claim that there is a dimension of reality that surpasses is a dimension of reality that surpasses observable phenomena, independent of observable phenomena, independent of individual perception, that includes core individual perception, that includes core generative mechanisms that may or may not generative mechanisms that may or may not be activated depending on context.be activated depending on context.

Thus…in this study-Thus…in this study-

CR is a perspective that can illuminate mechanisms CR is a perspective that can illuminate mechanisms embedded in clinical settings & interventions and embedded in clinical settings & interventions and facilitate undrstanding of the outcomes that may or facilitate undrstanding of the outcomes that may or may not resultmay not result

It is a theoretical base that informs the choice & It is a theoretical base that informs the choice & development of study interventions as well as the development of study interventions as well as the interpretation of study resultsinterpretation of study results

For critical realists explanatory power derives not from For critical realists explanatory power derives not from counting the co-presence of observable phenomena counting the co-presence of observable phenomena and inferring causation from empirical co-occurrence, and inferring causation from empirical co-occurrence, but from identifying causal mechanisms, how they but from identifying causal mechanisms, how they work, & discovering if they have been activated and work, & discovering if they have been activated and under what conditionsunder what conditions

(Kontos & Poland, 2009)(Kontos & Poland, 2009)

Critical Realism:Critical Realism:The integration of CR in health The integration of CR in health

care research can-care research can- Address the complexities of practice as a Address the complexities of practice as a

meaning-making activity;meaning-making activity; Optimise interventions for local Optimise interventions for local

circumstances;circumstances; Target crucial factors in the organisational Target crucial factors in the organisational

context that influence behaviour;context that influence behaviour; Disseminate evidence in a way that engages Disseminate evidence in a way that engages

practitioners in critical thought;practitioners in critical thought; Facilitate the achievement of best practice.Facilitate the achievement of best practice.

MethodologyMethodologyManley & McCormack (2004) articulate an Manley & McCormack (2004) articulate an ‘emancipatory’ model of PD defined by:‘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 Emancipatory Practice Development (EPD)Development (EPD)

The intent of EPD is to The intent of EPD is to increase effectiveness in increase effectiveness in patient-centred care patient-centred care through enabling of through enabling of healthcare teams to healthcare teams to transform the culture & transform the culture & context of carecontext of care

EPD is EPD is characteristic ofcharacteristic of the 3 phases which the 3 phases which

underpin Critical Social underpin Critical Social Science – consciousness Science – consciousness raising, becoming raising, becoming motivated to take action, & motivated to take action, & finally taking actionfinally taking action

Critical Realist Evaluation Critical Realist Evaluation (RE)(RE)

Proponents of RE Proponents of RE (Pawson 2002; Wilson & McCormack 2006)(Pawson 2002; Wilson & McCormack 2006) argue that the central question is not argue that the central question is not whether certain interventions work in a whether certain interventions work in a generalisable way, but what will work with generalisable way, but what will work with these ‘actors’ in this setting at this timethese ‘actors’ in this setting at this time

This enables understanding of relationships This enables understanding of relationships between the innovation & structural & between the innovation & structural & agential properties that inform uptake, need agential properties that inform uptake, need for refinement, & factors important for for refinement, & factors important for replicationreplication

Realist Evaluation offers researchers a more Realist Evaluation offers researchers a more complete picture of what is happening with complete picture of what is happening with EPD programmes and why it is happeningEPD programmes and why it is happening

The Context, mechanism, outcome formula The Context, mechanism, outcome formula is based on the principles of realism – real is based on the principles of realism – real (mechanisms); actual (events which may or (mechanisms); actual (events which may or may not be observed); empirical (evidence may not be observed); empirical (evidence of observable events & experiencesof observable events & experiences

The outcome is to describe the existing or The outcome is to describe the existing or non-existing relationship between the 3 non-existing relationship between the 3

Evaluation: Guided by Evaluation: Guided by principles of Realist principles of Realist

EvaluationEvaluation Complements EPD (distinguishes when Complements EPD (distinguishes when

context and facilitation may exert context and facilitation may exert influence)influence)

Evaluates the relationship between Evaluates the relationship between context, mechanism and outcome (tcontext, mechanism and outcome (thus hus the mechanism employed ‘makes sense the mechanism employed ‘makes sense of’ the specific outcome pattern observed)of’ the specific outcome pattern observed)

Informs the transferability of EPD Informs the transferability of EPD processes into differing contexts processes into differing contexts (Wilson & (Wilson & McCormack, 2006)McCormack, 2006)

Manley & McCormack (2004) argue Manley & McCormack (2004) argue that any evaluation framework should that any evaluation framework should

answer 5 essential questions about answer 5 essential questions about interventions:interventions:

Whether it works?Whether it works? Why it works?Why it works? For whom it works?For whom it works? Under what circumstances it works?Under what circumstances it works? What has been learnt to make it What has been learnt to make it

work?work?

Enables the adoption of a systematic Enables the adoption of a systematic approach to developmental work and approach to developmental work and its evaluationits evaluation

Enables the review of the evidence Enables the review of the evidence base underpinning practice base underpinning practice developmentsdevelopments

Enables PD consumers to make Enables PD consumers to make judicious decisions about applicability judicious decisions about applicability within their own particular context within their own particular context

(McCormack 2007)(McCormack 2007)

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

Context Mechanism OutcomeContext Mechanism OutcomeExternal & 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 ExerciseM1(B)Leadership programme facilitated using action learning approach

O(1)Philosophical core values establishedO(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 challengedO(4)Clear continence criteria identifiedExpert knowledge clarifiedO(5)Increased practitioner confidence

C(4)Lack of formal systems for receiving feedback

M1(D) 360 feedback O(6)Increased confidenceIncreased awareness of roles of othersIncreased 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 developedReceptive practice development culture.

Linkages between evidence, the context in which Linkages between evidence, the context in which it is implemented and the practice development it is implemented and the practice development processes involved in facilitating its use in processes involved in facilitating its use in practice are considered by referring to the practice are considered by referring to the

(PARIHS) project (PARIHS) project (Kitson et al, 1998)(Kitson et al, 1998) Emancipatory practice development is coherent Emancipatory practice development is coherent

with the PARIHS framework as both highlight the with the PARIHS framework as both highlight the significance of effective facilitation and significance of effective facilitation and transformational leadership in achieving transformational leadership in achieving

successful implementation.successful implementation.

Data Collection – first stepsData Collection – first steps

Following the logic of critical realism, Following the logic of critical realism, qualitative & quantitative methods qualitative & quantitative methods of data collection can serve to of data collection can serve to identify causal generative identify causal generative mechanisms of existing caremechanisms of existing care

These reveal contradictions between These reveal contradictions between espoused & enacted practice, & espoused & enacted practice, & existing barriers to best practiceexisting barriers to best practice

Data CollectionData CollectionA number of quantitative & qualitative A number of quantitative & qualitative

instruments were employed:instruments were employed: Context Assessment Index – 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 Observational Tool – The observational schedule was semi-structured and

developed from the EOC continence benchmark standard and Manley’s developed from the EOC continence benchmark standard and Manley’s cultural indicators (2000). This provided the focus for observation of ‘good cultural indicators (2000). This provided the focus for observation of ‘good practice’.practice’.

Continence Audit – reviewed the provisions for good continence care Continence Audit – reviewed the provisions for good continence care within the unit including facilities, access to continence aids, staff within the unit including facilities, access to continence aids, staff education programmes etc.education programmes etc.

Focus Group – this followed analysis of data previously collected & was Focus Group – this followed analysis of data previously collected & was used to gain views on the context of continence practice within the unit, & used to gain views on the context of continence practice within the unit, & insight into observational data collected.insight into observational data collected.

Provides differing sources of evidence; Provides differing sources of evidence; creates a more meaningful and deeper understanding of the creates a more meaningful and deeper understanding of the changing context;changing context; and enhances validity and credibility of findings.and enhances validity and credibility of findings.

Findings – Phase 1 Stage 1Findings – Phase 1 Stage 1

The findings from the context assessment index (CAI) The findings from the context assessment index (CAI) indicated the presence of an extremely strong and indicated the presence of an extremely strong and positive practice context within the unit prior to the positive practice context within the unit prior to the introduction of facilitation interventions.introduction of facilitation interventions.

The observational study which was undertaken at this The observational study which was undertaken at this time and identified specific cultural indicators which time and identified specific cultural indicators which supported the presence of a strong practice culture.supported the presence of a strong practice culture.

The unit scored highly when audited against the The unit scored highly when audited against the criteria for continence, bladder & bowel care within criteria for continence, bladder & bowel care within the Essence of care continence benchmarks. The the Essence of care continence benchmarks. The results demonstrated a high overall compliance rate.results demonstrated a high overall compliance rate.

Group/Standard Scores forContext Assessment Index (CAI)

A B C D

Group/StandardA B C D

Perc

enta

ge (

%)

100

95

90

85

80

75

70

65

60

55

50

45

40

35

30

25

20

15

10

5

0

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

Group/Standard Scores forCAI 2

A B C D

Group/StandardA B C D

Perc

enta

ge (

%)

100

95

90

85

80

75

70

65

60

55

50

45

40

35

30

25

20

15

10

5

0

B=Culture 60.16 C=Leadership 51.43

D=Evaluation 62.17

Cont…Cont… The results of the focus group emphasised contradictions The results of the focus group emphasised contradictions

within the initial findings and underlined tensions that within the initial findings and underlined tensions that existed within the team. existed within the team.

The views expressed by participants, at this stage, were The views expressed by participants, at this stage, were inconsistent with some of the findings arising from the CAI inconsistent with some of the findings arising from the CAI & observational exercise. This implied that there was a & observational exercise. This implied that there was a difference between how the team wanted to work together difference between how the team wanted to work together and the reality of practice. and the reality of practice.

Key issues initially emerged around the areas of insight & Key issues initially emerged around the areas of insight & consciousnessconsciousness of practice culture of practice culture, shared purpose, , shared purpose, leadership, teamwork, evaluation processes, assessment & leadership, teamwork, evaluation processes, assessment & planning of careplanning 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 Thank you for listening!listening!

Randal ParlourRandal ParlourNMPDU NMPDU

Iona House, Ballyshannon.Iona House, Ballyshannon.Co. DonegalCo. Donegal

IrelandIrelandrandal.parlour@hse.ierandal.parlour@hse.ie