Noyes Jane, Lewis Mary, Bennett Virginia, Widdas David, Brombley Karen
Centre for Health-Related Research, School of Healthcare Sciences, Bangor University, UK.
Royal United Hospital Bath NHS Trust, UK.
J Adv Nurs. 2014 Jan;70(1):220-37. doi: 10.1111/jan.12169. Epub 2013 May 28.
To report the first large-scale realistic nurse-led implementation, optimization and evaluation of a complex children's continuing-care policy.
Health policies are increasingly complex, involve multiple Government departments and frequently fail to translate into better patient outcomes. Realist methods have not yet been adapted for policy implementation.
Research methodology - Evaluation using theory-based realist methods for policy implementation.
An expert group developed the policy and supporting tools. Implementation and evaluation design integrated diffusion of innovation theory with multiple case study and adapted realist principles. Practitioners in 12 English sites worked with Consultant Nurse implementers to manipulate the programme theory and logic of new decision-support tools and care pathway to optimize local implementation. Methods included key-stakeholder interviews, developing practical diffusion of innovation processes using key-opinion leaders and active facilitation strategies and a mini-community of practice. New and existing processes and outcomes were compared for 137 children during 2007-2008.
Realist principles were successfully adapted to a shorter policy implementation and evaluation time frame. Important new implementation success factors included facilitated implementation that enabled 'real-time' manipulation of programme logic and local context to best-fit evolving theories of what worked; using local experiential opinion to change supporting tools to more realistically align with local context and what worked; and having sufficient existing local infrastructure to support implementation. Ten mechanisms explained implementation success and differences in outcomes between new and existing processes.
Realistic policy implementation methods have advantages over top-down approaches, especially where clinical expertise is low and unlikely to diffuse innovations 'naturally' without facilitated implementation and local optimization.
报告首次由护士主导的针对一项复杂儿童持续护理政策的大规模实际实施、优化及评估情况。
卫生政策日益复杂，涉及多个政府部门，且常常无法转化为更好的患者结局。现实主义方法尚未应用于政策实施。
研究方法——运用基于理论的现实主义方法进行政策实施评估。
一个专家小组制定了该政策及支持工具。实施与评估设计将创新扩散理论与多案例研究相结合，并采用了现实主义原则。英国12个地区的从业者与顾问护士实施者合作，对新决策支持工具和护理路径的项目理论及逻辑进行调整，以优化本地实施。方法包括关键利益相关者访谈、利用关键意见领袖制定创新扩散的实际流程以及积极的促进策略和一个小型实践社区。在2007 - 2008年期间，对137名儿童的新旧流程及结局进行了比较。
现实主义原则成功应用于更短的政策实施和评估时间框架。重要的新实施成功因素包括促进实施，使能对项目逻辑和本地情况进行“实时”调整，以最适合不断发展的有效理论；利用本地经验性意见改变支持工具，使其更符合本地情况及有效做法；以及拥有足够的现有本地基础设施来支持实施。有十种机制解释了实施成功以及新旧流程在结局上的差异。
现实主义政策实施方法比自上而下的方法具有优势，特别是在临床专业知识水平较低且若无促进实施和本地优化就不太可能“自然”扩散创新的情况下。
