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1.  Development and Preliminary Testing of a Framework to Evaluate Patients' Experiences of the Fundamentals of Care: A Secondary Analysis of Three Stroke Survivor Narratives 
Nursing Research and Practice  2013;2013:572437.
Aim. To develop and test a framework describing the interrelationship of three key dimensions (physical, psychosocial, and relational) in the provision of the fundamentals of care to patients. Background. There are few conceptual frameworks to help healthcare staff, particularly nurses, know how to provide direct care around fundamental needs such as eating, drinking, and going to the toilet. Design. Deductive development of a conceptual framework and qualitative analysis of secondary interview data. Method. Framework development followed by a secondary in-depth analysis of primary narrative interview data from three stroke survivors. Results. Using the physical, psychosocial and relational dimensions to develop a conceptual framework, it was possible to identify a number of “archetypes” or scenarios that could explain stroke survivors' positive experiences of their care. Factors contributing to suboptimal care were also identified. Conclusions. This way of thinking about how the fundamentals of care are experienced by patients may help to elucidate the complex processes involved around providing high quality fundamentals of care. This analysis illustrates the multiple dimensions at play. However, more systematic investigation is required with further refining and testing with wider healthcare user groups. The framework has potential to be used as a predictive, evaluative, and explanatory tool.
doi:10.1155/2013/572437
PMCID: PMC3705979  PMID: 23864946
2.  The prevention and reduction of weight loss in an acute tertiary care setting: protocol for a pragmatic stepped wedge randomised cluster trial (the PRoWL project) 
Background
Malnutrition, with accompanying weight loss, is an unnecessary risk in hospitalised persons and often remains poorly recognised and managed. The study aims to evaluate a hospital-wide multifaceted intervention co-facilitated by clinical nurses and dietitians addressing the nutritional care of patients, particularly those at risk of malnutrition. Using the best available evidence on reducing and preventing unplanned weight loss, the intervention (introducing universal nutritional screening; the provision of oral nutritional supplements; and providing red trays and additional support for patients in need of feeding) will be introduced by local ward teams in a phased way in a large tertiary acute care hospital.
Methods/Design
A pragmatic stepped wedge randomised cluster trial with repeated cross section design will be conducted. The unit of randomisation is the ward, with allocation by a random numbers table. Four groups of wards (n = 6 for three groups, n = 7 for one group) will be randomly allocated to each intervention time point over the trial. Two trained local facilitators (a nurse and dietitian for each group) will introduce the intervention. The primary outcome measure is change in patient’s body weight, secondary patient outcomes are: length of stay, all-cause mortality, discharge destinations, readmission rates and ED presentations. Patient outcomes will be measured on one ward per group, with 20 patients measured per ward per time period by an unblinded researcher. Including baseline, measurements will be conducted at five time periods. Staff perspectives on the context of care will be measured with the Alberta Context Tool.
Discussion
Unplanned and unwanted weight loss in hospital is common. Despite the evidence and growing concern about hospital nutrition there are very few evaluations of system-wide nutritional implementation programs. This project will test the implementation of a nutritional intervention across one hospital system using a staged approach, which will allow sequential rolling out of facilitation and project support. This project is one of the first evidence implementation projects to use the stepped wedge design in acute care and we will therefore be testing the appropriateness of the stepped wedge design to evaluate such interventions.
Trial registration
ACTRN12611000020987
doi:10.1186/1472-6963-13-299
PMCID: PMC3750564  PMID: 23924302
Malnutrition; Stepped wedge; Nutritional decline; Nutritional screening; MUST; Nutritional support; Oral nutritional supplement; Red tray; Evidence implementation; Knowledge translation; Feeding assistance; Nursing
3.  Measuring the context of care in an Australian acute care hospital: a nurse survey 
Background
This study set out to achieve three objectives: to test the application of a context assessment tool in an acute hospital in South Australia; to use the tool to compare context in wards that had undergone an evidence implementation process with control wards; and finally to test for relationships between demographic variables (in particular experience) of nurses being studied (n = 422) with the dimensions of context.
Methods
The Alberta Context Tool (ACT) was administered to all nursing staff on six control and six intervention wards. A total of 217 (62%) were returned (67% from the intervention wards and 56% from control wards). Data were analysed using Stata (v9). The effect of the intervention was analysed using nested (hierarchical) analysis of variance; relationships between nurses' experience and context was examined using canonical correlation analysis.
Results
Results confirmed the adaptation and fit of the ACT to one acute care setting in South Australia. There was no difference in context scores between control and intervention wards. However, the tool identified significant variation between wards in many of the dimensions of context. Though significant, the relationship between nurses' experience and context was weak, suggesting that at the level of the individual nurse, few factors are related to context.
Conclusions
Variables operating at the level of the individual showed little relationship with context. However, the study indicated that some dimensions of context (e.g., leadership, culture) vary at the ward level, whereas others (e.g., structural and electronic resources) do not. The ACT also raised a number of interesting speculative hypotheses around the relationship between a measure of context and the capability and capacity of staff to influence it.
We propose that context be considered to be dependent on ward- and hospital-level factors. Additionally, questions need to be considered about the unit of measurement of context in studies of knowledge implementation--is individual (micro), ward (meso) or hospital-level (macro) data most appropriate? The preliminary results also raise questions about how best to utilise this instrument in knowledge translation research.
doi:10.1186/1748-5908-5-60
PMCID: PMC2923100  PMID: 20673373
4.  Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges 
Background
The PARiHS framework (Promoting Action on Research Implementation in Health Services) has proved to be a useful practical and conceptual heuristic for many researchers and practitioners in framing their research or knowledge translation endeavours. However, as a conceptual framework it still remains untested and therefore its contribution to the overall development and testing of theory in the field of implementation science is largely unquantified.
Discussion
This being the case, the paper provides an integrated summary of our conceptual and theoretical thinking so far and introduces a typology (derived from social policy analysis) used to distinguish between the terms conceptual framework, theory and model – important definitional and conceptual issues in trying to refine theoretical and methodological approaches to knowledge translation.
Secondly, the paper describes the next phase of our work, in particular concentrating on the conceptual thinking and mapping that has led to the generation of the hypothesis that the PARiHS framework is best utilised as a two-stage process: as a preliminary (diagnostic and evaluative) measure of the elements and sub-elements of evidence (E) and context (C), and then using the aggregated data from these measures to determine the most appropriate facilitation method. The exact nature of the intervention is thus determined by the specific actors in the specific context at a specific time and place.
In the process of refining this next phase of our work, we have had to consider the wider issues around the use of theories to inform and shape our research activity; the ongoing challenges of developing robust and sensitive measures; facilitation as an intervention for getting research into practice; and finally to note how the current debates around evidence into practice are adopting wider notions that fit innovations more generally.
Summary
The paper concludes by suggesting that the future direction of the work on the PARiHS framework is to develop a two-stage diagnostic and evaluative approach, where the intervention is shaped and moulded by the information gathered about the specific situation and from participating stakeholders. In order to expedite the generation of new evidence and testing of emerging theories, we suggest the formation of an international research implementation science collaborative that can systematically collect and analyse experiences of using and testing the PARiHS framework and similar conceptual and theoretical approaches.
We also recommend further refinement of the definitions around conceptual framework, theory, and model, suggesting a wider discussion that embraces multiple epistemological and ontological perspectives.
doi:10.1186/1748-5908-3-1
PMCID: PMC2235887  PMID: 18179688

Results 1-4 (4)