Coffey Alice, Hartigan Irene, Timmons Suzanne, Buckley Catherine, Lehane Elaine, O'Loughlin Christina, O'Connell Selena, Cornally Nicola
Health Implementation Science and Technology Cluster, Health Research Institute, University of Limerick, Limerick, Ireland.
Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland.
Implement Sci Commun. 2021 Dec 11;2(1):137. doi: 10.1186/s43058-021-00241-7.
The importance of providing evidence-based palliative care for people with dementia is increasingly acknowledged as important for patient outcomes. In Ireland, evidence-based guidance has been developed in order to address key features of dementia palliative care, including the management of pain, medications and hydration and nutrition. The aim of this study was to identify and explore the factors affecting the implementation of evidence-based guidance on dementia palliative care.
The Consolidated Framework for Implementation (CFIR) guided a mixed-method pre-post study. One guidance document pertaining to the management of pain, medication or hydration and nutrition was implemented in three long-term care facilities. Participatory action research in the form of work-based learning groups was used to implement the guidance, drawing on a situational analysis (pre-implementation). Staff questionnaires and audits were conducted pre- and post-implementation while champion interviews were also conducted post-implementation.
Features of the guidance, the inner setting components such as readiness to change, and the process of implementation were most frequently identified as impacting implementation. Components of the outer setting, such as external policy incentives and individual characteristics, featured less commonly. Data from qualitative interviews revealed that the guidance was perceived as advantageous or complimentary to previous care provided. Within the inner setting, leadership and support from other colleagues facilitated implementation. However, limited availability of other healthcare professionals to assist with carrying out guidance actions presented a barrier in some facilities. The external facilitators of the work-based learning groups (WBLGs) were perceived as experienced and encouraged active participation and reflection on practices. Despite the challenge of releasing staff to attend the WBLGs, quantitative data demonstrated reduced staff de-motivation amongst those who did attend was noted post-implementation (pre-Mdn = 19.50 versus post-Mdn = 22.00, U = 497.00, p = 0.07).
A situational analysis informed by the CFIR framework in conjunction with a participatory action research approach helped to advance the implementation of the guidance. The progress of implementation depended on the extent to which evidence-based care was previously being implemented at each site. Post-implementation analysis using CFIR identified challenges to address in future projects such as staff cover and timing of training to facilitate attendance for staff with different working hours. Facilitators included multidisciplinary engagement with the intervention and champions at each site to support the implementation process.
为痴呆症患者提供循证姑息治疗对于患者预后的重要性日益得到认可。在爱尔兰，已制定循证指南以解决痴呆症姑息治疗的关键特征，包括疼痛管理、药物治疗以及水合作用和营养。本研究的目的是识别和探讨影响痴呆症姑息治疗循证指南实施的因素。
实施后混合方法研究以整合实施框架（CFIR）为指导。在三个长期护理机构实施了一份关于疼痛、药物或水合作用及营养管理的指导文件。以工作学习小组形式开展的参与式行动研究被用于实施该指南，研究基于情境分析（实施前）。在实施前后进行了员工问卷调查和审核，同时在实施后还进行了倡导者访谈。
指南的特征、内部环境因素（如变革准备程度）以及实施过程最常被认为会影响实施。外部环境因素，如外部政策激励和个人特征，较少被提及。定性访谈数据显示，该指南被认为对先前提供的护理具有优势或补充作用。在内部环境中，领导和其他同事的支持促进了实施。然而，在一些机构中，其他医疗保健专业人员协助执行指导行动的可用性有限，这成为了一个障碍。基于工作的学习小组（WBLGs）的外部促进者被认为经验丰富，并鼓励积极参与和对实践进行反思。尽管让员工参加WBLGs存在挑战，但定量数据表明，实施后参加的员工中工作积极性下降的情况有所减少（实施前中位数 = 19.50，实施后中位数 = 22.00，U = 497.00，p = 0.07）。
以CFIR框架为依据的情境分析与参与式行动研究方法相结合，有助于推进指南的实施。实施进度取决于每个机构先前实施循证护理的程度。使用CFIR进行的实施后分析确定了未来项目中需要解决的挑战，如人员配备和培训时间安排，以方便不同工作时间的员工参加。促进因素包括多学科参与干预以及每个机构的倡导者支持实施过程。
