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Title: A qualitative case study of the implementation and adoption of an evidence-based intervention used by informal carers and community-based care providers
Author: Mathieson, Amy
ISNI:       0000 0004 8504 8221
Awarding Body: University of Manchester
Current Institution: University of Manchester
Date of Award: 2019
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Background: Most developed countries have an ageing population; people are living longer, often with multiple long-term conditions. To reduce pressure on hospital services and meet the preferences of people to be cared for and later die at home, there has been a shift towards providing more care at home. Despite this, in the UK, home visiting services, namely district nursing, are declining and the majority of patients die in acute care. Family carers are crucial to enabling patients' to die at home, and interventions offering practical information to prepare carers for this role are required. Luker and colleagues (2015) developed and evaluated such an intervention: The Caring for Someone with Cancer booklet. Whilst the booklet received positive responses from family carers and district nurses, questions regarding its implementation remained, suggesting further feasibility work. Furthermore, the evidence-base for effective implementation is limited, particularly within community nursing. Therefore, an exploration of how the intervention and future evidence-based practice (EBP) could be integrated into community nurses' routine practice is needed. Aims: To explore and evaluate the processes involved in the implementation and adoption of the booklet intervention in community nursing, including barriers and facilitators. To explore how implementation can be sustained. To critique the use of Normalization Process Theory (NPT) to guide and evaluate implementation of the booklet intervention. Methods: This study had two phases, both utilising a qualitative case study design. A mixed qualitative method approach was chosen, combining semi-structured interviews and focus groups with observations. In addition, documents were collected and referred to, to support data analysis. Phase 1 explored how the booklet has been used within a large NHS Community Trust. Sixteen community practitioners recruited across the Trust participated October 2015 and March 2016. In addition, 14 former and current family carers participated in either a focus group or telephone interview April and July 2016. Phase 2 utilised Participatory Action Research principles and NPT to actively implement the booklet in four sites (two Nursing Homes, one District Nurse Team and a Hospice@Home Team). A total of 46 participants from the four sites took part in the study May 2016 to June 2017. Most took part in one stage of the data collection process (pre- or post-implementation). Reasons for this included work commitment, staff rostering, participants leaving the organization or site withdrawal from the study. Action research teams (researcher and Internal Facilitators) in each site met regularly to discuss the study. Meetings were recorded and analysed in conjunction with the interviews and observations. A framework approach to analysis was adopted, in order to compare findings across the two phases. Normalization Process Theory was used as a lens through which to view the findings. Findings: Evidence of all the NPT constructs and components were found in the data. The NPT constructs Coherence and Collective Action helped explain the work people do to enact the delivery of the booklet and barriers to its use. Specifically, practitioners' decision to adopt the intervention was based on interactional work with family carers and relatives. Community nurses claimed they 'know' the patient/carers' information needs and thus 'know what's best', sometimes resulting in the withholding of information. Additionally, people redefined and modified the intervention to use it in nursing home settings, and for different conditions. Organizational-level characteristics and conditions, including workforce and predictability of processes; management support; priorities and lack of time; organizational ethos; and communities of practices also influenced practitioners' engagement with the intervention. Due to an unstable work environment, community nurses focused on short-term rather than long-term goals, precluding practice development. Conclusion: Implementation and adoption in community nursing is complex, and influenced by both individual and organizational-level factors. Whilst it is recognised by community nurses that their practice should be based on evidence, many dismissed new EBP due to timing of implementation and uncertainty surrounding adoption. Community nurses reduced uncertainty by taking control and 'championing certainty' - following Trust procedures or resisting change - rather than 'accepting uncertainty'. To encourage the uptake of EBP, communities of practice should be nurtured and practitioners should be given opportunities to critically reflect upon taken-for-granted practices. Paternalistic practices appear to persist and need to be replaced with partnership approaches. The evidence generated can assist future implementation in this setting, and improve support for family carers.
Supervisor: Luker, Karen ; Grande, Gunn Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: End of life care ; Implementation ; Home care ; Family carers ; Normalization Process Theory ; Evidence-based Practice