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Conceptual framework for START project. Adapted from the PARIHS framework [28]. PARIHS, Promoting Action on Research Implementation in Health Services; START, Sustaining Transfers through Affordable Research Translation. 

Conceptual framework for START project. Adapted from the PARIHS framework [28]. PARIHS, Promoting Action on Research Implementation in Health Services; START, Sustaining Transfers through Affordable Research Translation. 

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Background: Bridging the research-practice gap is an important research focus in continuing care facilities, because the population of older adults (aged 65 years and over) requiring continuing care services is the fastest growing demographic among countries in the Organisation for Economic Co-operation and Development (OECD). Unlicensed practitio...

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... by Powell et al . (2012) concluded that understanding the frequency, intensity, and fidelity of interventions is an important next step in the field of implementation science [19]. Sustaining Transfers through Affordable Research Translation (START) is a randomized controlled trial (RCT); its purpose is to study the effectiveness of reminders to support the sustainability of an affordable mobility innovation by health care aides in supportive living facilities. It will determine which combination of frequency and intensity of reminders most effectively sustains the sit-to-stand activity. Specifically, it will look at peer-based and paper-based reminders, which we will elaborate upon below. This project will help identify how to strike a balance between the desired effects of an innovation and the resources invested to bring them about. START is a collaborative research project that will link interdisciplinary researchers with end-knowledge users involved in policy, advocacy, practice, and education, in striking such a balance. Importantly, this project will bridge the research-to-practice gap by examining the effectiveness and efficiency of reminder interventions to support the sustainability [5] of a research-based mobility innovation (the sit-to-stand activity) [7,20]. A reminder is defined as patient- or encounter-specific information that is provided verbally, on paper, or on a computer screen; such reminders are designed to prompt a health professional to recall information, which would usually be en- countered through their general education, in medical records, or through interactions with peers, and subse- quently remind them to perform the appropriate care based on up-to-date evidence [21]. START will examine two specific knowledge translation reminder interventions: 1) paper-based reminders; and 2) peer-based reminders. In the absence of literature to guide us about the frequency and intensity of reminders, we decided how to operationalize the low and high levels of frequency and intensity in consultation with collaborative members. For frequency, a monthly modification of the reminders for the high frequency arm aligns with the rhythm of other monthly managerial responsibilities; in contrast for the low frequency reminder, we decided that every 3 months would be infrequent but would align with quarterly managerial responsibilities. For intensity, it was agreed that paper- based reminders are low intensity and commonly used in clinical settings [10]. For the high intensity reminder a socially-based ‘ peer reminder ’ was favored. Peer reminders have not been reported in the literature; how- ever, we did find one article reporting the use of health care aide champions in a long-term care facility [22] and a protocol trialing a socially-based intervention to move fall prevention evidence into long-term care practices [23]. Media richness theory suggests that the richness of the medium should be selected to fit the nature of the mes- sage (in this case a non-routine change in health care aide practice). For example, face-to-face communication with a peer providing reminders (rich medium) offers the possi- bility of handling multiple information cues, providing rapid feedback, and establishing a personal focus [24]. Compared with a paper-based reminder, which is on the lower end of the media richness hierarchy, the peer reminder might be expected to be more effective in sup- porting a practice change. Social influence theory emphasizes that behavior is ‘ guided ... by assumptions, beliefs, and values held by peers and by prevailing practices and social norms that define appropriate behavior ’ [25]. Thus, in developing a strategy to promote the uptake of a specific evidence-based practice, the social influence of peers can be leveraged to influence the behavior of health care aides. Our team has experience with paper-based and peer reminders in the MOVE study, but in that study we did not measure health care aide uptake outcomes. (Resident outcomes were measured). In our experience, paper-based reminders were easily introduced, but the peer reminders required more time and effort to implement. Anecdotally, the health care aides providing the reminders appreciated the recognition they received from their managers and experienced satisfaction in their roles. To summarize, the level of reminders will vary in frequency (monthly versus every 3 months) and intensity (paper reminders versus paper reminders plus peer reminders). We will also study facility context [26,27] and processes that influence the effectiveness of reminders to support the ongoing uptake of the activity by health care aides in 24 supportive living facilities. This research is guided by the Promoting Action on Research Implementation in Health Services (PARIHS) conceptual framework [28], which posits that successful implementation of evidence into practice involves con- nections between facilitation [29], evidence [30], and context [31] (Figure 1). If these three domains are ‘ strong , then there is an in- creased likelihood that evidence will be adopted into practice. The PARIHS framework accounts for the complex and multilevel nature of initial adoption of innovations in long- term care settings [32]. Key concepts in the PARIHS framework are similar to concepts identified as important for the sustainability of innovations in two systematic reviews [5,9]. We have adapted the PARIHS framework to include the sustainability of innovations. Facilitation involves structures and processes that enable individuals, teams, and organizations to change [29]. The facilitation processes in the current study pertain to the use of reminders as a type of knowledge translation intervention. Evidence is defined as knowledge derived from a variety of sources that has been tested and deemed credible [30]. The evidence to be integrated into practice for the START project is the sit-to- stand activity that has been studied with older adults in both laboratory and clinical settings. Context is defined as the en- vironment in which people receive healthcare services, and in which the proposed change is to be implemented [31]. START will examine factors that the PARIHS framework identifies as foundational to a facility ’ s context (the prevailing culture, leadership roles, and how evaluation is conducted) in supportive living facilities in a western Canadian city. We will describe how the key concepts of the PARIHS framework relate to START in the following paragraphs. Given the novel nature of the high intensity intervention (peer reminders), we will use educators to conduct focus groups with health care aides before starting the clinical trial to further develop this knowledge translation intervention. These focus groups will address how to best tailor the peer reminders for the participating facilities. We will ask health care aides to consider the proposed reminder, and ask participants to brainstorm possible ways to operationalize the reminder system. During the focus groups we will ask health care aides to evaluate and discuss the merits of their proposed ideas, as well as ideas suggested by the lead educator. Possible examples of the peer reminder may include: 1) discussing case studies; 2) discussing documentation; 3) discussing sticker reminders; 4) describing ‘ good news stories ’ ; and 5) peers celebrating other peers. The success of the health care aide peer reminder role hinges on achieving the right fit between the role and the health care aide recruited to the role. Experienced health care aides who have established working relationships with their peers and health team members will contribute to the credibility of the peer reminder role. Health care aides are more likely to feel comfortable in the peer reminder role if they demonstrate the ability to: influence others; attract respect from peers, residents, and professional staff; exhibit effective communication skills; show enthusiasm for new practices; and demonstrate a passion for their role as a caregiver. It is likely that the peer reminder health care aides will have experience championing other new practices in their facilities, such that their mentorship skills may be more developed. Ideally the peer reminder health care aides will work full-time and on both day and evening shifts. It is important to note that paper-based reminders are common; the studies in the Grimshaw et al . review largely used paper-based reminders in primary care settings [11]. Reminders with a paper-based component were also most frequent in a review exclusively examining physician reminders [10]. Paper-based reminders worked well when few care measures were involved and when the reminders were integrated into the clinical workflow. However, peer-based reminders are a novel intervention and, to the best of our knowledge, no study has attempted to use this intervention to support the sustainability of an innovation. Thus, the focus groups will help guide, formulate, and thus facilitate an appropriate, feasible peer-based reminder for health care aides working in continuing care facilities. We decided to study the sustainability of the sit-to-stand activity because it possesses most of the attributes of an innovation that are thought to increase the likelihood of successful adoption [33], and research evidence supports the sit-to-stand activity ’ s effectiveness in maintaining mobility. Rogers ’ attributes of a successfully adopted innovation include: 1) relative advantage (requires minimal training of health care aides or clients); 2) compatibility (builds upon existing routines); 3) low complexity (low cost innovation conducted by regular staff; does not involve an important increase in the time required to care for clients); 4) trialability (easily tried and adapted to individual clients); and 5) observability (outcome can be visible) [6]. Process data from the MOVE study suggest that health care aides can ...

Citations

... A majority of these articles (n = 89) were empirical studies [58-62, 90, 95-97, 122-127, 149-170, 215-224, 243-256, 285-312], and about half of these described the use of PAR-IHS as an overall guide to frame the study (e.g., [58,60,168,222,285,303]). A similar finding was apparent in the 11 protocols [23-25, 36, 37, 47-50, 56, 57]; about half of these also referred to the use of PARIHS to guide and frame the study design (e.g., [47,48,50,57]). ...
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Background: The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework. Methods: This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail. Results: The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated. Conclusions: In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.
... The protocol for this cluster randomized trial, using a stratified factorial design, is published elsewhere [8]. To summarize briefly, we recruited long-term care and assisted living facilities from the greater Edmonton region. ...
... A peer reminder was a CA who reminded and encouraged fellow CAs to carry out a new care practice with residents. Their role was to provide brief (2-3 min) formal reminders during regularly scheduled unit meetings either once a month (high frequency), or once every three months (low frequency), depending on their randomized intervention arm [8]. The content and timing of this formal reminder was at the discretion of the peer reminder and normally lasted 5 min or less. ...
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Background: The study purpose was to compare the effectiveness of monthly or quarterly peer reminder knowledge translation interventions, with monthly or quarterly paper-based reminders, to sustain a mobility innovation, the sit-to-stand activity. Method: A cluster RCT using a stratified 2 × 2 factorial design was conducted in 24 Canadian residential care facilities with 416 residents and 54 peer reminder care aides. The 1-year intervention included two intensities of reminders (high: socially based peer reminders delivered by volunteer care aides to other care aides; low: paper-based reminders posted in residents' rooms), at two frequencies (monthly; every 3 months). Intervention fidelity was assessed using questionnaires and observations. Monthly sustainability rate of the sit-to-stand activity was calculated as the percentage of opportunities that residents successfully completed the activity in 30 days. Residents' sustainability rates were analyzed using a linear mixed model that mirrored the clustered repeated-measures factorial trial design. The model included a random intercept to account for clustering within sites. An unstructured covariance structure characterized the interdependence of repeated measures over time. Results: Twenty-four sites were randomized. One site was excluded because of falsifying data, leaving 23 sites and 349 residents for intention-to-treat analysis. Paper reminders were implemented with high fidelity across all arms (91.5% per protocol), while the peer reminders were implemented with moderate fidelity in the monthly group (81.0% per protocol) and poor fidelity in the quarterly group (51.7% per protocol). At month 1, mean sustainability ranged from 40.7 to 47.2 per 100 opportunities, across the four intervention arms (p = 0.43). Mean rate of sustainability in the high intensity, high frequency group diverged after randomization, yielding statistically significant differences among the groups at 4 months which persisted for the remainder of the trial. After 12 months, the mean sustainability in the high intensity, high frequency group was approximately twice that of the other three groups combined (64.1 versus 37.8 per 100 opportunities, p < 0.001). Conclusions: A monthly peer reminder intervention was more effective than a quarterly peer reminder intervention, a monthly paper-based reminder intervention, and a quarterly paper-based reminder intervention, in supporting care aides to sustain a mobility innovation in residential care facilities over 1 year. Trial registration: ClinicalTrials.gov , NCT01746459. Registered 11 December 2012: https://clinicaltrials.gov/ct2/show/NCT01746459 .
... The Promoting Action on Research Implementation in Health Services (PARiHS) model is one of the best-documented and most widely used models that emphasize the role of context (Attieh et al., 2013;Cummings et al., 2007;Doran et al., 2012;Kitson et al., 1998;Rycroft-Malone et al., 2004;Seers et al., 2012;Slaughter et al., 2013). PARiHS suggests that successful translation of evidence into practice depends on three key factors: 1) the nature of the evidence; 2) the context; and 3) the facilitating factors in the environment. ...
... • Facilitation: Facilitating environmental conditions can be defined as a variety of strategies that can drive the adoption of PPs (Kitson et al., 1998). In the PARiHS model, the facilitator can be an individual with skills in change management or personal and organizational development (Slaughter et al., 2013). In addition to a facilitator, the organization can leverage other, more technical facilitation mechanisms, such as documents, training meetings, checklists for applying best practices (Seers, 2012), and technological resources to facilitate access to evidence (Doran et al., 2012). ...
Article
Objective The objective of this article is to examine the application of MSD prevention practices among nursing staff and to identify organizational factors that may or may not support their application. Methods We measured the application of prevention practices and its determinants by means of a questionnaire filled out by 399 nurses and nursing staff in Canada. A qualitative component was conducted with two focus groups in order to validate and enrich the interpretation of the survey results. Results Results show that most respondents “often” (4) apply MSD prevention practices in their daily professional tasks. Significant differences were observed based on position, mission of the institution, degree, and training. Conclusions The characteristics of the nursing staff (position, training, etc.) and the specificities of the setting must be taken into consideration in MSD prevention interventions for nursing staff.
... This qualitative study is part of a larger research project, the Sustaining Transfers through Affordable Research Translation (START) study (Slaughter, Estabrooks, Jones, Wagg, & Eliasziw, 2013). The START study evaluated the effect of varying frequencies and intensities of reminders on the adoption of the sit-to-stand activity by HCAs across 23 residential care facilities in Alberta, Canada. ...
Article
Aims and objectives: To explore the experience of HCAs encouraging residents living in residential care to complete the sit-to-stand activity and to identify the strategies HCAs used to integrate the activity into their daily work routines. Background: Decreased mobility in advanced ageing is further reduced when entering a residential care facility. Interventions such as the sit-to-stand activity have been shown to have a positive effect on the mobility of older people. There is evidence to suggest that healthcare aides are able to support residents to complete the sit-to-stand activity as part of their daily work routines; however, little is known about how healthcare aides actually do this with residents living in residential care. Design: A qualitative interview study included seven purposively sampled HCAs working in residential care facilities. Semistructured interviews were analysed using inductive qualitative content analysis. Results: The HCAs' experience with the sit-to-stand activity was represented by the following four categories: Resident participation, Feeling misunderstood and disrespected, Time and workload, and Management involvement. HCAs identified three strategies to help them support residents to complete the sit-to-stand activity: Motivating residents, Completing activity in a group and Using time management skills. Conclusions: HCAs reported some encouragement from managers and cooperation from residents to complete the sit-to-stand activity with residents; however, they also felt constrained by time limitations and workload demands and they felt misunderstood and disrespected. HCAs were able to identify several strategies that helped them to integrate the sit-to-stand activity into their daily routines. Implications for practice: This study highlights the challenges and supportive factors of implementing the sit-to-stand activity into the daily work routine of HCAs. The study also identifies the strategic role of nurse managers when implementing interventions in residential care facilities.
Article
The incidence of musculoskeletal disorders (MSD) in the healthcare professional population is concerning. In particular, the high incidence of back injuries is an issue for nurses. Although many MSD prevention initiatives are being implemented, these practices are not succeeding in reducing MSDs. Why are these efforts struggling to close the gap between knowledge and practice? This article aims to report on individual and organizational factors that may influence nurses' implementation of MSD prevention practices. A survey was sent to nurses in the Quebec health and social services network. A total of 399 questionnaires were completed and analyzed. The results revealed that nurses have the required knowledge on MSD prevention practices, but have difficulty applying them in their professional context. It would appear that successful implementation of MSD prevention practices relies mainly on organizational factors, including management support, organizational culture, feedback mechanisms, and training that is adapted to the work environment.
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Background To improve patient outcomes many healthcare organizations have undertaken a number of steps to enhance the quality of care, including the use of evidence-based practices (EBPs) such as clinical practice guidelines. However, there is little empirical understanding of the longer-term use of guideline-based practices and how to ensure their ongoing use. The aim of this study was to identify the determinants and knowledge translation interventions (KTIs) influencing ongoing use of selected recommendations of an institutional pain policy and protocol over time from an organizational perspective and 10 years post implementation on two units within an acute care setting. Methods We conducted a mixed methods case study guided by the Dynamic Sustainability Framework of an EBP 10 years post implementation. We examined protocol sustainability at the nursing department and unit levels of a multi-site tertiary center in Canada. Data sources included document review ( n = 29), chart audits ( n = 200), and semi-structured interviews with nurses at the department ( n = 3) and unit ( n = 16) level. Results We identified 32 sustainability determinants and 29 KTIs influencing ongoing use of an EBP in acute care. Three determinants and eight KTIs had a continuous influence in all three time periods: implementation phase (0–2 yrs), sustained phase (>2–10 yrs.), and at the 10-year mark. Implementation of KTIs evolved with the level of application (e.g., department vs. unit) to fit the EBP within the context highlighting the need to focus on determinants influencing ongoing use. Sustainability was associated with continual efforts of monitoring and providing timely feedback regarding adherence to recommendations. KTIs used to embed recommendations into routine practices/processes positively influenced high adherence rates. Use of a participatory approach for implementation and sustainment and linking KTIs designed to incrementally address low adherence rates facilitated sustainment. Conclusion This research provides insight into the relationship between implementation and sustainability determinants and related KTIs during implementation and sustained use phases. Unique determinants identified by department and unit nurses reflect their different perspectives toward the innovation based on their respective roles and responsibilities. KTIs fostered changed behaviors and facilitated EBP sustainment in acute care. Findings confirm the concept of sustainability is a dynamic “ongoing process.”
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Introduction : faisant partie intégrante des soins infirmiers, les soins de plaies représentent un enjeu de santé publique et sont une préoccupation.Contexte : en dépit des guides de pratique et l’existence de lignes directrices, un écart persiste entre les données probantes et la pratique clinique.Objectifs : faire l’état de la situation et répertorier les obstacles au transfert optimal des connaissances en soins de plaies chez les infirmières.Méthode : une revue intégrative suivant la méthodologie de Whittemore et Knafl (2005) a été effectuée. La recherche des données reliées au transfert des connaissances en soins de plaies dans la pratique infirmière a été réalisée dans six bases de données.Résultats : parmi les 82 écrits répertoriés, 13 articles ont été retenus pour l’analyse. Les écrits, tous publiés en anglais, soulèvent l’écart entre la théorie et la pratique infirmière en soins de plaies. Des obstacles reliés aux connaissances, aux attitudes et au contexte contribuent à entretenir celui-ci.Discussion : les soins infirmiers auraient avantage à être optimisés relativement aux soins de plaies. La situation des nouvelles infirmières et la réalité des milieux de soins ruraux sont peu explorées dans ce contexte. Conclusion : un plan stratégique adapté à chaque établissement de santé permettrait d’améliorer la qualité de la pratique en soins de plaies.
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Background: Dissemination of evidence-based practices has been a long-standing challenge for healthcare providers and policy makers. Research has increasingly focused on effective knowledge translation (KT) in healthcare settings. Aims: This study examined the effectiveness of two KT interventions, informal walkabouts and documentation information sessions, in supporting care aide adoption of new evidence-based practices in continuing care. Methods: The Sustaining Transfers through Affordable Research Translation (START) study examined sustainability of a new practice, the sit-to-stand activity completed with residents in 23 continuing care facilities in Alberta, Canada. At each facility, two informal walkabouts and two documentation information sessions were conducted with care aides during the first 4 months. To assess their effect, uptake of the sit-to-stand activity was compared 4 days prior to and 4 days after each intervention, as well as the entire first and fourth months of the study were compared. Data were analyzed using mixed linear regression models created to estimate the changes in uptake. Results: Data were collected from 227 residents. After controlling for age, sex, dementia, and mobility, a 5.3% (p = .09) increase in uptake of the mobility activity was observed during the day shift and 6.1% (p = .007) increase in uptake of the mobility activity during the evening shift. Site size had a significant effect on the outcome with medium-sized facilities showing a 12.6% (SE = .07) increase over small sites and a 18.2% (SE = .05) increase over large sites. These results suggest that repeated KT interventions and sufficient time are key variables in the successful implementation of new practices. Linking evidence to action: Consideration of time, repetition, and facility-specific variables such as size may generate simple, cost-effective KT interventions in healthcare settings.
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With provincial policy changing institutional care provision for older adults who are unable to safely remain at home, supportive living represents a new middle-ground to provide care for older adults. We compared characteristics of supportive living staff and residents to those in long-term care (LTC), using facility and staff surveys, as well as administrative Resident Assessment Instrument (RAI) data, to describe differences and similarities between facility types. Data analysis included t-tests, chi-square tests, ridit analyses and odds ratios. Participants from 15 supportive living facilities were compared to participants from eight LTC homes. Supportive living healthcare aides were younger, worked fewer years and were more likely to work full time than LTC healthcare aides. LTC residents were more likely than supportive living residents to have: cognitive impairment, medical instability, and activities of daily living dependence. This knowledge, which situates supportive living in the new care continuum, is useful for policy makers and administrators deciding on interventions and clinical guidelines for care groups.