DevelopmentoftheContextAssessmentIndex

(CAI)
April2008
PrincipleInvestigators
ProfessorBrendanMcCormack
ProfessorofNursingResearch
InstituteofNursingResearch/SchoolofNursing
UniversityofUlster,Jordanstown
Belfast,NorthernIrelandBT310QW

ProfessorGeraldineMcCarthy
HeadofSchool
SchoolofNursingandMidwifery
UniversityofCollegeCork
RepublicofIreland

ResearchAssociates
JayneWright
UniversityofUlster
NursingDevelopmentCentre
ThirdFloor,BostockHouse
RoyalHospital
Belfast,NorthernIrelandBT126BA
AliceCoffey
SchoolofNursingandMidwifery
UniversityofCollegeCork
RepublicofIreland
PaulSlater
Room17C03,SchoolofNursing
UniversityofUlster,Jordanstown
Belfast,NorthernIrelandBT310QW

Contents
Acknowledgements
Executivesummary

{1}
{2}

Section1:Introductionandbackground
Backgroundtothestudy

{5}

Section2:Aimsandobjectives
Researchaims
Studysites
Researchteam

{6}
{6}
{6}

Section3:Literaturereview
Prevalenceofcontinenceproblems
Managementofcontinenceproblems
Evidencebasedpractice
ThePARIHSframework
Context
Workplaceculture
Leadership
Evaluation

{7}
{7}
{8}
{8}
{9}
{9}
{10}
{10}

Section4:Phase1Methodologyandanalysisprocess
Casestudymethodology
Datacollection
Dataanalysis
Consentandethicalconsiderations
Finalanalysisusingthecontextframework

{11}
{11}
{12}
{12}
{13}

Section5:Phase1Findingsfromtheanalysis
RoyalCollegeofPhysicians(RCP)auditscheme
Facilityaudit
StaffKnowledgeQuestionnaire
Observationofpractice
Focusgroups
Finalanalysisusingthecontextframework
Discussionoffindings
Conclusions

{15}
{15}
{16}
{16}
{17}
{18}
{18}
{20}

Section6:Phase2DevelopingandtestingtheContextAssessmentIndex
Introduction
Prepilottesting
Pilottestingoffaceandcontentvalidity
Largesampletestingofvalidity
Testretest
Modificationstothemodel

{21}
{21}
{22}
{22}
{27}
{28}

Usabilitytestingbytelephoneinterview
Summaryofdatacollectionandanalysis
FinalrevisionstotheCAI

{30}
{31}
{31}

Section7:Discussionandrecommendations
Discussion
Conclusions
Recommendationsforfutureresearch

{32}
{33}
{35}

References
Appendices

{36}
{39}

Listofappendices

Appendix1 Datacollectioninstruments

{39}

Appendix2 Focusgrouptopics

{44}

Appendix3 Extractsfromanalysisusingcontextframework

{45}

Appendix4 Feedbacksheetforprepilottesting

{48}

Appendix5 Feedbacksheetpilotforpilottesting

{49}

Appendix6 Interviewscheduleafterreliabilitytesting

{50}

Appendix7 TheContextAssessmentIndex(CAI)andtheCAIGuide

{51}

Listoftablesandfigures

Table1

Contextframework

{9}

Table2

Summaryofmethodsofdatacollection,sampleandanalysis

{13}

Table3

Exampleofstatementdevelopment

{14}

Table4

Extractfromdataanalysisusingcontextframework

{19}

Table5

LargesamplevaliditytestinNorthernIreland

{23}

Table6

LargesamplevaliditytestinRepublicofIreland

{24}

Table7

Itemsandcorrespondingfactorscoresforthecontextualindicatorsquestionnaire

{25}

Table8

Correlationmatrixoffactorscontainedinthecontextualindicatorsquestionnaire

{26}

Table9

Homogeneityofthesixfactorsinthecontextualindicatorsquestionnaire

{26}

Table10

Meanscoresofeachconstructofthecontextualindicatorsquestionnaire

{27}

Table11

CorrelationofconstructscoresattimesT1andT2

{28}

Table12

CorrelationofamendedconstructscoresattimesT1andT2

{29}

Table13

MappingofCAIelementstothecontextframework

{33}

Table14

Revisedcontextframeworkfollowingorganisationofdataforanalysis

{34}

Figure1

ScatterplotofresponsesfromtimeT1andtimeT2withalineofbestfit

{29}

Acknowledgements
Thisstudywouldnothavebeenachievedwithoutthecommitmentofallthoseinvolved.Wethankallthestaffwhoconsented
totakepartandwillinglygavetheirtime,andwethankElizabethKaneforadministrationsupportthroughoutthestudy.
TheresearchwasfundedbytheRepublicofIrelandHealthResearchBoardandtheNorthernIrelandDepartmentofHealth,
SocialServicesandPublicSafety(DHSSPS)R&DOffice(20042006).

Executivesummary
ThisreportistheculminationofatwoyearcollaborativeprojectbetweennursingresearchteamsintheUniversityofUlsterand
UniversityCollegeCorktodevelopatooltoassessthepracticecontextinwhichcontinenceismanaged.Theresearchwas
fundedbytheNorthernIrelandDepartmentofHealth,SocialServicesandPublicSafety(DHSSPS)R&DOfficeandtheRepublicof
IrelandHealthResearchBoard.

Backgroundtothestudy
Thesignificanceofincontinencetothelivesofolderpeopleanditseffectonhealthandsocialcareresourceshasledto
continencebecominganationalhealthcareissue.TheChiefNurseforEnglandstatedthatsheexpectednursestogivemuch
moreattentiontocontinenceasitisafundamentalaspectofnursingcare(DH2001a).Despitemajoradvancementsinthe
evidencebaseunderpinningcontinencepromotionandthemanagementofincontinence,therecontinuestobelittleemphasis
ondetailedandindividualisedassessmentoronprovidingprogramsoftreatment.Thepredominantapproachtomanagementis
conservative,involvingcostlyrelianceoncontainmentwiththeuseofcontinencepads.Lackofadequateknowledgeamong
clinicalstaffisacknowledgedaswellasalackofawarenessofhowknowledgeandskillscouldbeenhanced.Continenceisnot
seenbypractitionersasahighprioritywithinthecompetingdemandsofnursing.
Inrehabilitationsettingsforolderpeople,thepromotionofcontinenceandimprovedmanagementofincontinenceisakey
themeforthedevelopmentofpracticeinnursing.Providingpractitionerswiththeevidenceofbestpracticealonedoesnot
directlyleadtothisbeingimplementedintopractice(RycroftMaloneetal.2004).Manyfactorshavebeendebatedwithinthe
literaturetoexplainthegapbetweenevidenceofbestpracticeandtherealityofwhattakesplaceinpractice.Theseinclude
nursesattitudesandperceptionsofresearchutilisation(Parahoo1999),andnursesabilitytounderstandandinterpretresearch
(McCaughanetal.2002).RycroftMaloneandcolleagues(2004)highlighttheimportanceofevidencederivedfroma
combinationofempiricalsourcesmatchedwithpatientsexperiences,localcontextfactorsandclinicalexperience(Rycroft
Maloneetal.2004).AframeworkknownasthePromotingActiononResearchImplementationinHealthServicesframework
(PARIHS)(Kitsonetal.1998;RycroftMaloneetal.2002)proposedthatsuccessfulimplementationofevidenceisdependenton
theinterrelationshipofthreekeyelements;thenatureoftheevidencederivedfrom(research,clinicalexperience,andpatients
preference),thequalityofthepracticecontext(culture,leadershipandevaluation)andexpertfacilitation(characteristics,role
andstyle)(McCormacketal.2002).
Thepracticecontext(theculture,leadershipandevaluationprocesses)thereforeneedstobeconducivetotheutilisationof
researchevidence.Acomprehensivemethodofassessmenttoincludeallelementsofpracticecontextwasnotavailableatthe
timeofthestudy,thereforeacollaborativeresearchstudybetweentheUniversityofUlsterandUniversityCollegeCork
commencedtoidentifythecontextualindicatorsofbestpracticeincontinencecare,whichwouldinturnleadtothe
developmentofanassessmenttooltomeasurepracticecontext.

Sections1and2:Backgroundandaimsofthestudy
Thesesectionsprovideabackgroundtothestudy,highlightingtheoverallpurposeofthistwoyearallIrelandresearchstudy,
betweentheUniversityofUlsterandtheUniversityCollegeCork,whichbeganin2004.Thestudyaimswereto:(1)identifythe
contextualindictorsthatenableorhindereffectiveevidencebasedcontinencecareinrehabilitationsettingsforolderpeople;
and(2)developatool(theContextAssessmentIndex,CAI)toenablepractitionerstoassessthecontext(leadership,cultureand
evaluation)withinwhichcontinencecareisprovided.PrincipleInvestigatorswereProfessorGeraldineMcCarthyfromthe
UniversityCollegeCorkandProfessorBrendanMcCormackfromtheUniversityofUlster.AResearchAssociatewasresponsible
fortheplanningandcarryingoutofallaspectsofthestudyateachsite.TheyweresupportedbyathirdResearchAssociatefor
thedevelopmentofthetoolfromtheUniversityofUlster.Theresearchwasconductedintwophases.Phase1consistedofan
indepthcasestudydesignsetwithinthePromotingActiononResearchImplementationinHealthServices(PARIHS)framework
(Kitsonetal.1998,RycroftMaloneetal.2002)toidentifythefactorsthatenhanceandhinderevidencebasedcontinencecare.
AttheendofPhase1,keyindicatorsarisingfromallstrandsofthedatacollectionandanalysiswereidentifiedanddeveloped
intoatoolforassessingpracticecontextinordertoestablishpracticedevelopmentapproachesthatleadtopersoncentred
continencepractices.

Section3:Reviewoftheliterature
Aliteraturereviewpresentsevidenceoftheprevalenceofcontinenceproblemsandconsequencesforolderpeople,e.g.that
manyolderpeopledonotliketoadmittohavinganincontinenceproblem.Continenceproblemsareoftenseenbynursesand
olderpeopleasaninevitableconsequenceofaginganddifficulttotreat.TheeffectontheresourcesoftheNHShasledto
continencebecominganationalhealthcareissue,andrecentpolicydocumentssuchastheGoodPracticeinContinenceServices
andtheNationalServiceFrameworkforOlderPeople(DH2001a)promotecontinenceserviceswithafocusonproactive
assessmentandappropriatetreatment.Oftensimplemanagementmeasurescanresolvetheproblem.Evidencedbased
protocolsandcarepathwayshavebeendeveloped.However,researchhasdemonstratedthatpractitionersarecontinuingto
providereactivecontinencemanagementratherthanapplyavailableevidenceofbestpractice.
Theutilisationofevidenceinpracticeisalsodiscussedanditisdemonstratedthatthereremainsagapbetweenevidenceof
bestpracticeandrealityinpractice.PARIHS(Kitsonetal.1998,RycroftMaloneetal.2002)proposesthatsuccessful
implementationofevidenceisdependentontheinterrelationshipofthreekeyelementsthenatureoftheevidence,the
qualityofthecontext,andexpertfacilitation.ThepracticecontextdefinedbyMcCormacketal.(2002)asenvironmentor
settinginwhichpeoplereceivehealthcareservicesisrarelystraightforwardbutcanbeseenasconstantlychangingandwith
manydiverseculturesoperatingatdifferentlevelsintheorganisation.Thechallengewastoidentifyandunderstandthe
contextualindicatorsthathinderorenhancetheimplementationofevidencedbasedcontinencecareandmanagementfor
olderpeople.ThiswasthemainaimofPhase1oftheproject.

Sections4and5:Phase1findings
ThesesectionsdescribethemethodsusedinPhase1ofthestudyandtheresults.Theoverallresearchquestionwas:Whatare
thecomponentsofpracticecontextthatenableorhinderproactiveapproachestothepromotionofcontinenceandtreatment
inrehabilitationsettingsforolderpeople?Thereweretwostudysites,a78bedrehabilitationunitinNorthernIrelandandan
80bedrehabilitationunitintheRepublicofIreland.Anumberofquantitativeandqualitativeresearchinstrumentswere
employed(eachoftheseisdescribedaswellasthemethodofdataanalysis):

RoyalCollegeofPhysiciansauditschemeforcontinence(Brocklehurst1998).

Staffknowledgequestionnaire(Irwinetal.2001).

Semistructuredobservationofpractice(frameworkusingManley'sculturalindicators)(Manley2000a,DH2001b).

Focusgroups.

Usingthecontextframeworktoanalysethedata,apictureemergedofthecontextwithinthecaresitesanditssignificanceto
evidencedbasedcontinencecare.Theevidencesuggeststhatthecontext(leadership,cultureandevaluation)wasweakandnot
conducivetopersoncentredcontinencecareandmanagement.Clearlythereisdevelopmentworkneededtocreateacontext
thatreflectsstrongleadership,cultureandeffectiveevaluation.Byutilisingthecontextframework,theresearchteamwereable
toidentifythespecificcontextualissuesthatwerehinderingandenablingthedeliveryofpersoncentredcontinencecareand
themesthatarosefromthisprocess.Thesethemesformedthebasisofthedevelopmentofatooltomeasurecontexthence
theContextAssessmentIndex(CAI).

Section6:Phase2findings
ThissectioncoversthedevelopmentoftheContextAssessmentIndexthroughtestingandretestingitsvalidity,reliabilityand
usability.Themethodsofdatacollectionandthestagestodevelopmentoftheassessmenttoolareoutlined,fromtheinitial
statementsarisingfromtheanalysisofthedatawithinthecontextframework(alistofapproximately300items),through
piloting,revising,testingandretestingthetool.Developmentofthetoolwasundertakeninfivestages:

Prepilottestingforcomprehensivenessandspecificity.

Pilottestingforfaceandcontentvalidity.

Largesampletestingforfactoranalysispurposes.

Testretestforreliability,stabilityandhomogeneity.

Telephoneinterviewsforassessmentofusability.

Section7:Finaldiscussion
Thissectiondrawstogetherthefindingsfromthefactoranalysisandthetestingprocess.IngeneraltheContextAssessment
Indexcanbeconsideredavalidinstrumentaccordingtotheresultsofthestatisticalanalysis.Reliabilityisalsodemonstrated
throughatestretestprocess.Telephoneinterviewswerethenconductedwithnursemanagerswhohadtakenpartinthetest
3

retesttodiscusstheusabilityoftheCAI.OnthewholeresponsetotheusabilityoftherevisedCAIwaspositiveanditwas
encouragingthatmostoftherespondentsfoundthatithelpedthemreflectonpractice.
Thereportconcludeswiththeoverallfindingsofthestudyandsomerecommendationsforfurtherresearchandpractice.These
include:

ImplementingtheCAIinpractice,particularlyindesignatedclinicalareas,andevaluatingitsimpactondevelopingpractice.

TestingthevalidityandreliabilityoftheCAIindifferentspecialties.

Refiningthecontextframeworkbyexploringfurtherthemeaningofcontextanditsimpactonimplementingevidencein
practice.

AguidewasdevelopedtoaccompanytheCAIandthiswastestedandrefinedfollowingfeedbackfromtheinterviewees.A
processforinterpretingtheCAIwasalsodeveloped(tobetestedinaseparatestudy).

SECTION1
Introductionandbackground
Introduction
ThisreportisofatwoyearallIrelandresearchstudy(fundedbytheNorthernIrelandDHSSPSR&DOfficeandtheRepublicof
IrelandHealthResearchBoard)betweentheUniversityofUlsterandUniversityCollegeCork,begunin2004.Inbothlocations
thefocuswasarehabilitationsiteforolderpeople.Thestudydescribedinthisreportaimedtoachievetwothings:firstly,to
identifythecontextualindictorsthatenableorhindereffectiveevidencebasedcontinencecareinrehabilitationsettingsfor
olderpeople;secondly,todevelopatool(ContextAssessmentIndex,CAI)toenablepractitionerstoassessthecontext
(leadership,cultureandevaluation)withinwhichcontinencecareandmanagementisprovided.

Backgroundtothestudy
Inrehabilitationsettingsforolderpeople,thepromotionofcontinenceandimprovedmanagementofincontinenceisakey
themefordevelopmentwork.Atpresent,practiceinthisareagenerallyreflectstheneedtohelppeoplewhoexperience
continenceproblems,remaincleanandtopreventskindamage.Despitemajoradvancementsintheevidencebase
underpinningcontinencepromotionandmanagementofincontinence,therecontinuestobelittleemphasisplacedondetailed
andindividualisedassessmentoronprovidingprogrammesoftreatment.AnauditinaNorthernIrelandHealthandSocial
ServicesTrust(Irwinetal.2001)suggestedinadequateassessment,poorrecordkeepingandconsequentlyonlyalimiteddegree
ofactivetreatment.Thepredominantapproachtomanagementwasconservative,involvingcostlyrelianceonpads.Irwinand
colleaguesidentifiedalackofadequateknowledgeamongclinicalstaff,aswellasalackofawarenessofhowknowledgeand
skillscouldbeenhanced.IntheRepublicofIrelandcontinencemanagementintheHealthServiceExecutiveSouthernArea(HSE
South)isdirectedbyregionalguidelinesandsupportedbyonecontinenceadvisor.Ataunitlevel,thepracticeofcontinence
managementisamixofconservativeintervention,education,behaviourmodificationandfacilitation.Anumberoffacilitiesin
theHSESouthareintheprocessofformulatinglocalpolicies.Earlyindicationsfromaninitialexplorationofpracticesina
rehabilitationsettingforolderpeopleinBelfast,NorthernIrelandsuggestthatexistingcarereflectsasimilarpicture.Current
approachestocareaddresssafetyandthereductionofrisk.Despitemajoradvancementsintheevidencebaseunderpinning
continencepromotionandmanagementofincontinence,theapproachtocareremainsreactiveandconservative,ratherthan
proactiveandtherapeutic(DH2001b).Existingevidenceabouttheutilisationofresearchinpracticeidentifiescontextasakey
issue.McCormacketal.(2002)identifiedthreeelementsofpracticecontextthatneedtobeassessedinorderforresearch
evidencetobeutilisedexistingmeasuresofeffectiveness,leadershipandworkplaceculture.
Asacomprehensivemethodofassessmenttoincludeallelementsofpracticecontextwasnotavailable,thiscollaborative
researchstudybetweentheUniversityofUlsterandUniversityCollageCorkcommenced.Theaimwastoidentifythe
contextualindicatorsofbestcontinencecarepractice,whichwouldinturnleadtothedevelopmentofanassessmenttoolto
measurepracticecontext.

SECTION2
Aimsandobjectives
Researchaims
Thesewere:

Todeterminecontextualindicatorsthatenablesorinhibitseffectivecontinencepromotionandcontinencemanagement.

Todevelopatoolforassessingthecontextualfactorsinrehabilitationsettingsforolderpeopleinordertointroduce
appropriatecontinencepromotionstrategies.

Totestthereliabilityandvalidityofthetoolinrehabilitationsettings.

Theoverallresearchquestionwas;Whatarethecomponentsofpracticecontextthatenableorhinderproactiveapproachesto
thepromotionofcontinenceandtreatmentinrehabilitationsettingsforolderpeople?
Toaddressthisquestion,theresearchwasconductedintwophases.Phase1consistedofanindepthcasestudydesignset
withinthePromotingActiononResearchImplementationinHealthServices(PARIHS)framework(Kitsonetal.1998,Rycroft
Maloneetal.2002)toidentifythefactorsthatenhanceandhinderevidencebasedcontinencecare.AttheendofPhase1,key
indicatorsarisingfromallstrandsofthedatacollectionandanalysiswereidentifiedanddevelopedintoatoolforassessing
practicecontext.Thiswasdoneinordertoestablishpracticedevelopmentapproachesthatleadtopersoncentredcontinence
practices.Phase2focusedondevelopmentofthetoolandtestingitsvalidityreliabilityandusability.

Studysites
Thereweretwostudysites,a78bedrehabilitationunitinNorthernIreland(site1)andan80bedrehabilitationunitinthe
RepublicofIreland(site2).Therationalewastoallowtheidentificationofitemsforinclusioninthetool,whichwouldbe
culturallysensitive,andtoenablecomparisonsbetweenthetwocaresettings.Theresearchwascarriedoutsimultaneouslyin
eachsite,usingspecificresearchinstruments.

Researchteam
ThestudyhadtwoPrincipleInvestigators,ProfessorGeraldineMcCarthyfromtheUniversityofCorkandProfessorBrendan
McCormackfromtheUniversityofUlster.OneachsitetherewasaResearchAssociatewhowasresponsibleforplanningand
carryingoutofallaspectsofthestudy.AnadditionalResearchAssociateconductedthestatisticalanalysisforthedevelopment
oftheContextAssessmentIndex(CAI).TheResearchAssociatesmetfivetimesoverthecourseofthestudyandtheproject
teammetfourtimes.

SECTION3
Literaturereview
Prevalenceofcontinenceproblems
Theprevalenceofcontinenceproblemsamongolderpeopleisestimatedtobebetween30and50%(Buttonetal.1998).There
isawealthofliteraturethathighlightstheeffectofcontinenceproblemsonthequalityoflifeofolderpeople,suggestingthat
effectivecareandtreatmentcanpreventadmissiontolongtermcare(Wyman2003).Manyolderpeopledonotliketoadmitto
havinganincontinenceproblem(Cochran1998)andcontinenceisoftenseenbynursesandolderpeopleasaninevitable
consequenceofagingthatisdifficulttotreat(Blandetal.2003,Buttonetal.1998,Gray2003,ThompsonandSmith2002.
Furthermore,nursesdonotalwayshavethenecessaryskillsandknowledgetoundertakecontinenceassessmentandeffective
treatments(Baylissetal.2001).
ThesignificanceofcontinencetoolderpeopleandtheeffectontheresourcesintheNationalHealthService(NHS)hasledto
continencebecominganationalhealthcareissue.TheChiefNurseforEnglandstatedthatsheexpectednursestogivemuch
moreattentiontocontinenceasitisafundamentalaspectofnursingcare(DH2001a).
RecentpolicydocumentssuchastheGoodPracticeinContinenceServices(DH2000)andtheNationalServiceFrameworkfor
OlderPeople(DH2001a)promotesthedevelopmentofintegratedcontinenceserviceswithafocusonidentifyingpatients,
assessingtheirconditions,andputtingappropriatetreatmentinplace.Boththesepolicydocumentsaimtoraisenurses
awarenessofproactivecontinencecare.TheEssenceofCarebenchmarkingtoolkitincludesastandardforcontinence(DH
2001b)whichgoesfurtherthanraisingawarenessandofferspractitionerstheopportunitytoworkwithserviceuserstoreview
existingpracticeandmakeimprovements.Allthesedocumentsaimtopromoteantidiscriminatoryandpersoncentredmodels
ofpractice.

Managementofcontinenceproblems
Thediagnosticapproachtoincontinenceshouldincludeacarefulreviewofallorgansystems,asensitivebutdetailedhistory,
andafocusedphysicalexamination(SarkarandRitch2000,ThompsonandSmith2002).Mostpatientsalsorequireurodynamic
studiesand/orultrasoundscanningtofurtheraiddiagnosis.Theseinvestigationswillprovideinformationabouttheinternal
urethralsphincter,thebladderwalland/orthepresenceofanobstruction(SarkarandRitch2000).Therearealsobarriersto
continencethat,accordingtoThompsonandSmith(2002),havelittletodowiththeurinarytract.Anevaluationofsuchthings
asaccesstotoiletingfacilities,functionalandcognitiveability,andmotivationarethereforealsopertinentaidstodiagnosis.
Themanagementofincontinenceimpliestheuseofmeasuresdesignedtoachievesocialcontinence(HeathandWatson2002).
AccordingtotheRoyalCollegeofPhysicians(1995){notinrefs},urinaryincontinencecanbecuredoralleviatedinupto70%of
cases;thereforetheimplicationisthatanunderlyingcausecanbefoundforthesecasesandshouldbeinvestigated.Inastudy
byLandietal.(2003)todeterminethefactorsassociatedwithincontinenceincommunitydwellingelderlypeopleinItaly,
potentiallyreversibleriskfactorssuchasurinarytractinfectionsandenvironmentalbarriersfeaturedstrongly.Thereisample
evidenceaccordingtoSarkarandRitch(2000)thatnursingmeasures(e.g.hygiene,dietandfluidintake,careofbowels,bladder
retrainingandpelvicfloorexercises)areeffectiveinimprovingandrestoringcontinenceforthemajorityofpatients.
Variousotherstrategiesareusedtorestorecontinence,includingsurgeryandtheuseofmedicationaccordingtoHaslam(2004).
Conservativetreatmentsforurinaryincontinenceincludebladdertraining(scheduledvoidingaccordingtoatimetable),pelvic
musclerehabilitation(tostrengthenvoluntaryperiurethralmuscles,vaginalmusclesandtheanalsphincter),biofeedback(to
provideavisualorauditoryawarenessofthephysiologyofvoiding),andelectricalstimulation(tofacilitatethecontractionof
themusclesinurgeincontinence).Pharmacologicaltherapiessuchasanticholinergicdrugsforurgeincontinenceandoestrogens
forstressincontinencecanbeusedinadditionto(orinsteadof)behaviouraltherapies.Simplemeasuressuchasimproving
toiletingfacilities,removingenvironmentalbarriersandrestraintsandalteringmedicationsmayresolvetheproblem(Sarkarand
Ritch2000).Theuseofcontainmentproductssuchaspadsandpenilesheathscanalsoassistthemanagementofincontinence,
inconjunctionwithothertherapies.
Focusedandtargetedassessmentofcontinenceinolderpeopleisthemeanstodeterminingthemostappropriatetreatment
andcaretobeprovided(Gray2003,NSF2001a,Baylissetal.2000).However,aspractitionersdonotseecontinenceasahigh
prioritywithinthecompetingdemandsofnursing,assessmentsdonotgetmade(Gray2003).Patientsfeelthatassessmentsask
toomanyquestionsaboutsymptomsandtoofewabouttheemotionalimpactofincontinence(Rigby2001).Forpersoncentred
continencecare,practitionersshouldexplorehowcontinencerelatedproblemsaffectwellbeingineverydaylife(Palmer2002).
Evidencedbasedprotocolsandcarepathwayshavebeendevelopedthatarevaluableforensuringstandardisationof
continenceservices(forexample,Baylissetal.2000,Buttonetal.1998,Williamsetal.2002).However,despitetheevidence
7

thattreatmentsandlifechangescanmakeadifference,nursesseecontinenceproblemsasanacceptablepartofaging(NSF/DH
2001a);thisattitudeleadstoreactivecare,suchasreplacingwetpadsandclotheswithdryones(Irwinetal.2001,Palmer2000,
Thomas2001).
Wyman(2003)outlinesthefactors(orbarriers)thatinterferewithimplementationofevidencebasedcontinencepractice
educational,attitudinal,organisational,financialandprofessional.Interestingly,individualnursesknowledge,beliefsand
attitudesabouturinaryinfectionwerefoundtobeasignificantpredictorofnursingpractice(Cheater1992).Wyman(2003)
statesthateducationshouldaimtocreateattitudinalchangetowardscontinence.Availableevidencesuggeststhateducation
largelyfocusesonpalliativeratherthantherapeuticorrehabilitativenursingstrategies(Cheater1992),touchingonsuchaspects
asscheduledvoidingregimens,pelvicfloorexercises,surgicalprocedures,andlifestylechanges(reducingcaffeineintakeandso
on)(DH2001b).Pringleetal.(2002)highlightedtheresultsoftreatingolderpeoplewithdementiainspecialistunits.Theyused
promptedvoidingwithpatientswhowereimmobiletoimprovetheircontinence.
AnauditofnursescontinenceknowledgeconductedbyIrwinetal.(2001)supportsthefindingthatnurses'knowledgeabout
continencemustbeimproved.Theyobservedthatfewnursestaketheopportunitytoincreasetheirknowledge.
AccordingtoWyman(2003)anorganisationthatisnotopentoinnovationorthatisfocusedonkeepingcostsdownisabarrier
tooptimalcontinencemanagement.Thereportalsoidentifiedlimitednurseleadershipinthefieldofcontinencebecauseitis
notseenasapriorityoverthemanyothercompetingdemandsofnursing.Wymandemonstratedthatbehaviouralinterventions
wereofteneffectiveinreducingincontinenceinlongtermcare,butobservedthatonceastudyendedtheoldpractices
resumed('businessasusual')andthechangeswerenotsustained.
Theliteratureoncontinenceandolderpeopleillustratesagrowingbodyofknowledgeinsupportofevidencebasedcontinence
care.However,practitionersinthisfieldcontinuetoprovidereactivecontinencemanagement,ratherthanapplyavailable
evidenceofbestpractice.

Evidencebasedpractice
Overthepastfewyears,theissueofhowtotransferevidenceintopracticehasbeengivenmuchattention.Butclearlyproviding
practitionerswithevidenceofbestpracticealonedoesnotdirectlyleadtoimplementationinpractice(RycroftMaloneetal.
2004).Thereasonsforthisarecomplexandmanyfactorshavebeenproposedwithintheliteraturetoexplainthegapbetween
evidenceofbestpracticeandtherealityofwhatoccursinpractice,includingtheroleofnurses,theirattitudestoand
perceptionsofresearchutilisation(Parahoo1999)andtheirabilitytounderstandandinterpretresearch(McCaughanetal.
2002).RycroftMaloneetal.(2004)identifiedissueswithorganisationalsupport,relevanceofresearchtotheclinicalsetting,
approachestocollaborationandleadershipintheimplementationprocess,availabilityofresourcesandaccesstoevidenceas
factorscontributingtoknowledgeuseinpractice.
Whenevidenceisdiscussedintheliteraturethefocusismainlyonsystematic,conventional,publishedresearchstudies,with
randomisedcontroltrialsrecognisedasthemostvaluable.However,relativelyrecentworkbyRycroftMalone(RycroftMalone
etal.2004)highlightstheimportanceofpluralistformsofevidencethatderivefromempiricalsourcesmatchedwithpatients
experiences,localcontextfactors,andclinicalexperience.RycroftMaloneandcolleaguesdevelopedthePARIHSframeworkasa
modelforunderstandingthesignificanceofdifferingfactorspromotingknowledgeuseinpractice.

ThePARIHSframework
ThefullnameofthePARIHSframeworkisPromotingActiononResearchImplementationinHealthServicesFramework(Kitson
etal.1998,RycroftMaloneetal.2002).Itillustratesandmakessenseofthecomplexfactorsinvolvedinimplementingevidence
intopractice,andproposesthatsuccessfulimplementationofevidenceisdependentontheinterrelationshipofthreekey
elements:

Thenatureoftheevidence(research,clinicalexperience,andpatientpreference).

Thequalityofthecontext(culture,leadershipandevaluation).

Expertfacilitation(characteristics,roleandstyle)(McCormacketal.2002).

Eachoftheseelementshascharacteristicsspanningacontinuumofweaktostrong.Kitsonetal.(1998)proposesthatfor
successfulimplementation,theevidenceneedstoberobust,thecontextneedstobereceptivetochange,andappropriate
facilitationneedstobeused.Asthefocusofthestudywasthecontextwithinwhichcontinencecareandmanagementis
provided,thethreeelementsofcontextarediscussed.ThethreeelementsandtheircharacteristicsarepresentedinTable1.

Table1:Characteristicsofthecontextframework
ELEMENTS

WeakcharacteristicsStrongcharacteristics

Context

Lackofclarityaroundboundaries
Lackofappropriatenessandtransparency
Lackofinformationandfeedback
Lackofpowerandauthority
Notreceptivetochange

Boundariesclearlydefined(physical,social,cultural
andstructural)
Appropriateandtransparentdecisionmaking
processes
Informationandfeedback
Powerandauthorityunderstood
Receptivenesstochange

Culture

Unclearvaluesandbeliefs
Lowregardforindividuals
Taskdrivenorganisation
Lackofconsistency

Abletodefineculture(s)intermsofprevailingvalues
andbeliefs
Valuesindividualstaffandclients
Promoteslearningorganisation
Consistencyofindividualsroleorexperiencetovalue:
relationshipwithothers,teamworking,powerand
authority,rewards/recognition

Leadership

Traditional,commandandcontrolleadership
Lackofroleclarity
Lackofteamwork
Didacticapproachestoteaching/learning/
managing
Autocraticdecisionmakingprocesses

Transformationalleadership
Roleclarity
Effectiveteamwork
Enabling/empoweringapproachtoteaching/learning/
managing
Enabling/empoweringapproachtolearning/teaching/
managing

Evaluation

Absenceofanyformfeedbackandinformation
Narrowuseofperformanceinformation
sources
Evaluationsrelyonsingleratherthanmultiple
methods
Poororganisationalstructure

Feedbackonindividual,teamandsystems
Useofmultiplesourcesofinformationonperformance
Useofmultiplemethods(clinical,performanceand
experience)
Effectiveorganisationalstructure

Context
ContextisdefinedbyMcCormacketal.(2002;p.96)astheenvironmentorsettinginwhichpeoplereceivehealthcareservices.
Theenvironmentinhealthcareisrarelystraightforwardbutisconstantlychanging,withmanydiverseculturesoperatingat
differentlevelsthroughouttheorganisation.Researchisseenasprovidingevidenceofwhatmightbeachievedunderideal
circumstancesitcreatescontextfreeguidance.Ofcourseitisrecognisedthatwedonotworkincontextfreesituations,as
supportedbytheCanadianHealthServicesResearchFoundation(CanadianHealthServiceResearchFoundation(CHSRF)2005;
p.11)whoarguethatgettingevidenceintopracticeisnotcontextfreeandstate:'theroleofscienceissomewhatdetached
from,andunconcernedwith,itsapplicationtospecificcircumstances'.Thismeansthatresearchersneedconsiderthecontext
withinwhichtheresearchisbeingundertakenandtheeffectthecontextwillhavewhenthatevidenceisputintopractice.
Moreover,theroleofcontextintheresearchprocessneedstobefurtherelucidated(McCormacketal.2002).
Thedifficultyindefiningandcapturingtheconceptofcontexthasbeenlikenedto'tryingtocatchacloud(CHSRF2005;p.13).
Contextcanbeseenas'infinite'becauseitexistsinallworkplacecommunitiesandculturesthatareinfluencedbyeconomic,
social,political,fiscal,historicalandpsychosocialfactors(McCormacketal.2002).Fromareviewoftherelevantliteratureon
context,theCanadianFoundationsuggestedthatissuesdirectlyrelevanttohealthcareincludevalues,politicaljudgements,
resources,professionalexperienceandexpertise,habitsandtraditions,lobbyistsandpressuregroups,andpragmaticsand
contingencies(CHSRF2005).McCormack's(2002)identifiedthreeelementsofpracticecontextthatneedtobeassessedinorder
forresearchevidencetobeutilisedtheexistingmeasuresofeffectiveness,leadershipandculture.Becauseofthediverse
elementsofcontext,itcouldbeconcludedthatmultiplemethodsofachievingevidencebasedpracticeareneeded(Swinburnet
al.2005).McCormack'sthreeelementsofthecontextframeworkformthebasisforthestudyandarebrieflydescribedhere.

Workplaceculture
Organisationalculture
Organisationalresearchstudieshavemainlyfocusedonstructure,systemsandbehaviour(Manley2000a,b).VandenBergand
Wilderom(2004)describeorganisationalcultureasthegluethatholdsanorganisationtogetherandstimulatesanemployees
commitmenttotheorganisationtoperform;theysuggestthatevidenceofhowtooperationalisethisglueisrare.However,
Manley(2000a,b)arguedthatasaconcept,organisationalculturehaslittlesignificancetocliniciansandpatientsbecauseofits
focusonhighlevelstructures,systemsandprocesses.Manleyshowedthatindividualworkplaceshavetheirowncultural
9

characteristicswhichmaybeinfluencedbyorganisationalculturebutareuniquetoeachpracticesetting(i.e.context).These
uniquecharacteristicshavethegreatestinfluenceontheperceptionsandexperiencesofpatientsandstaffabouttheir
organisation(i.e.workplaceculture).

Transformationalculture
Manley(2004)definesanidealcultureas'transformational'becauseitisalwayschangingform,adaptingandrespondingtoa
changingcontext.Atransformationalcultureisbasedonvaluesthatenablestaffatalllevelstofeelempowered,todevelop
theirownpotential,andtobeinnovativeindevelopingpracticeandthusproducebestpracticeforpatients.Manley(2000b)
alsostatesthatthereisaneedforqualitativestudiestoobservetheculturesofworkplacesandtoprovideinformationonhow
tosuccessfullyimplementinnovativeworkinpractice.

Leadership
Muchhasbeenwrittenaboutwhatmakesagoodleader,butthefieldofnursinghashadsomedifficultyinestablishinggood
leadership(Cunningham1998,Girvin1998).Themosteffectiveleadersare'transformational'ones,whoarecommittedto
allowingthemselvesandotherstooptimisetheirskills,abilities,knowledge,andpotential(ManleyandDewing2002).Leaders
describedas'transformational'canbringdifferenttypesofevidencetogether(research,patientexperienceandclinical
experience)andimplementthatevidenceintopractice,sobringingaboutnewwaysofworking.Inthiswaytheycanchangethe
organisation'scultureandcreateacontextintowhichevidencebasedpracticecanbemoreeasilyintegrated(McCormack2002).
ThePARIHSframeworkpointsoutthateveryonecanbealeaderofsomething,andthatthepotentialforleadershipneedstobe
developedandreleased(RycroftMaloneetal2004)

Evaluation
Evaluatingpracticetakesmanyforms,fromtheuseofharddata(suchascosteffectivenessandlengthofstay)tosoftdata
(suchasthepatientsexperienceofpractice).Inaneffectiveculture,healthcareprofessionalsuseevidencegatheredfrom
varioussourcestomakedecisionsaboutindividualororganisationaleffectiveness;thisinturnisusedasanintegralpartof
accountabilityframeworksandstaffappraisalstrategies(McCormacketal.2002).Thiscultureembracespeerreview,userled
feedbackandreflectiononpractice,aswellasevidencefromthesystematicliteraturereviews,metaanalysesandauditof
effectiveness.Measurementisavitalpartofanyenvironmentthatseekstoimplementevidenceintopracticenomatterhow
complexthatmeasurementcanbe(McCormacketal.2002).
Thechallengeistoexplorewhichcontextualfactorshinderorenhancetheimplementationofevidencedbasedcareand
managementofolderpeoplewithcontinenceproblems.

10

SECTION4
Phase1Methodologyanddatacollection
Casestudymethodology
AccordingtoYin(1994)acasestudyisan'empirical'enquirythatinvestigatesacontemporaryphenomenonwithinareallife
context.Thisstudywasdesignedasacasestudybecausecasestudiesaregoodforexploringhumanaffairsandbecausetheyare
focused,reflectingrealitiesthatreaderscanempathiseandofferingrichdescriptionsofsocialconditions(Geertz1973).
Thecasestudyapproachweusedallowedindepthinvestigationofthe'context'inwhichcontinenceismanaged,withmultiple
sourcesofevidencegatheredfromtworehabilitationsitesforolderpeople.ThePARIHSframeworkwasusedtoguidethe
structureofthestudy,basedontheconstructsofculture,leadership,andevaluation.

Datacollection
Variousquantitativeandqualitativeresearchinstruments(seeAppendix1and2)wereemployedinPhase1ofthestudy:

RoyalCollegeofPhysicians(RCP)auditschemeforcontinence(Thisisonlyavailableinhardcopy(Brocklehurst1998)(see
Appendix1).

StaffKnowledgeQuestionnaire(seeAppendix1).

SemistructuredobservationofpracticeframeworkusingManley'sculturalindicators(Manley2000a)andEssenceofCare
(DH2001b)(Appendix1).

Focusgroups(Appendix2).

TheRoyalCollegeofPhysicians(RCP)auditscheme(Brocklehurst1998)
Itwasusedtocollectdataontheincidenceandmanagementofurinaryandfaecalincontinenceandofurethralcatheterisation.
TheRCPschemeincludesthreetypesofaudit:asinglepatientaudit,amultiplepatientaudit,andafacilityaudit.Foreachof
theseaudits,separatequestionnaireswereprovidedforurinaryincontinence,faecalincontinenceandurethralcatheterisation.
Inthisstudy,asinglepatientauditofurinaryincontinenceservedasapilotforthemainaudit.Themultiplepatient
questionnaireswereusedinthemainstudytoauditaseriesofpatientswithacontinenceproblemineachrehabilitationunit.
Thesequestionnairesrecordeddetailsoftheincidence,assessment,treatmentandfollowupofurinaryandfaecalincontinence
andurethralcatheterisation.Afacilityauditwascompletedincollaborationwithclinicalnursemanagersorcontinencelink
nursesinbothsites,toenablereviewofpoliciesandavailabilityofresourcesforcontinencepromotion.

StaffKnowledgeQuestionnaire(Irwinetal.2001)
Thisquestionnairehas27questionsdesignedtomeasurestaffawarenessandknowledgeofthecausesandtreatmentof
continenceproblems.Therearetwoparts;thefirstmeasuresperceivedknowledgeofcontinence;thesecondismultiplechoice
questionsaboutfactualknowledge.

Semistructuredobservationofpractice
NonparticipantobservationsofpracticewerecarriedoutinasemistructuredwayusingascheduledevelopedfromtheEssence
ofCarecontinencebenchmarks(DH2001b)andManley'sculturalindicators(Manley2000a).Thisprovidedafocusfor
observationofbestpractice.Atotalof16hoursofobservationsweremadeateachrehabilitationhome,eachonelastingfor
twohoursandcarriedoutatdifferenttimesofday.Thesewereundertakenbypractitionersfromthestudysiteareas.

Focusgroups
FocusgroupdiscussionstookplaceinbothstudysitestheRepublicofIrelandandinNorthernIreland.Variousmultidisciplinary
teammemberswereinvitedtoparticipatesothateachdisciplinewasrepresented.Intotal,26stafftookpart.Multidisciplinary
stafffrombothrehabilitationunitswereinvitedtoprovideopinionsonspecificissuesthatemergedfromanalysisofthedata.In
ordertohaveawiderangeofopinionsandanaccuraterepresentationofthestudypopulation,astratifiedsampleofthe
multidisciplinarystaffineachoftheparticipatingsiteswasinvitedtoparticipateinfocusgroupdiscussions(MaysandPope
2000).Kitzinger(1995)describesthefocusgroupapproachasgroupdiscussionsthatareorganisedtoexplorespecificissues.

11

Dataanalysis
Thedatawerecollectedandanalysedintwostages.

Stage1
Alldata(excludingthatfromthefocusgroups)wereanalysedtoidentifykeythemesusingthetenstageapproachforqualitative
analysis(Ely1991;lateradaptedbyMcCormack2002).
QuantitativedatawereanalysedusingtheRCPaudit,theKnowledgeQuestionnaire.TheNIVIO(Fraser2000)wasusedto
organisethequalitativedataandmanagetheanalysisprocess.Initialimpressionswerenotedfromthedataandalistof
tentativesubthemeswasdrawnup.Thesubthemeswererevisedandrefinedandnarrativeswereselectedtolinkthem
together.Thisprocessidentifiedanygaps(e.g.alackofdata)andassessedeachparticularcontextindictorasbeingtooweak
ortoostrong.

Stage2
Severaltopicswereidentifiedfordiscussionbythefocusgroups,inadditiontoissuesalreadyidentifiedbytheworkofManley
(2000a,b)onpatientandstaffculturalindicators,andEssenceofCare(DH2001b).Threespecificissuesemerged:

Howthetwounitsperformedinanumberofhighlightedareassuchasspecificcontinenceassessmentandclearrationale
fortreatment.

Howinformationandchoiceanddignitywereprovidedforpatientsineachunit.

Howknowledgeandskillincontinencemanagementwasprioritorisedwithintheteam.

Participantswereaskedtodescribetheirrolesincontinencepromotionandmanagementandtoassignresponsibilityfor
leadershipincontinencecare.

Consentandethicalconsiderations
Thestudygainedethicalapprovalatbothsites.Allstaffweregivenwritteninformationaboutthepurposeofthestudyandthe
focusgroupsandreceivedwrittenrequeststoparticipate.Meetingswereheldtoraiseanyconcernsandreinforce
confidentialityissues.Nonameswereusedinanypartofthestudy.Toensureacollaborative(overt)approach,nurseswere
givenwritteninformationpriortotheobservationstage.
Gaininginformedconsentbeforetheobservationscommencedwasproblematicbecausetheywereconductedinbusywards.
ThereforewefollowedtheadviceofSavage(2000)bygainingverbalconsentfromallpeopleexpectedtobeonthewardduring
thetimesoftheobservationandthenincludinganyunexpectedvisitorsandstaff.Noonedeclinedtotakepart.Nopatient
informationwascollectedsoconsentwasnotneeded,butanyoneintheareaoftheobservationsweregivenwritten
informationandexplanationsbeforehand.
Thenursingstaffidentifiedpatientswithacontinenceproblemwhowereapproachable.Thesepatientswereaskedforconsent
toreadandrecordinformationfromtheirnotes.Inthefirstinstance,thewardnurseaskedthesepatientsiftheresearcher
couldtalkwiththem.

12

Table2:Summaryofmethodsofdatacollectionandanalysis
Datacollectionmethod

Purpose

Samplesize

Dataanalysis

RoyalCollegeofPhysicians
auditscheme(Brocklehurst
1998)forreviewofexisting
incidenceandmanagementof
urinaryandfaecalincontinence
andurethralcatheterisation

Toquantifynumberof
olderpeoplewith
continenceproblems,
thetypesofproblem,
andapproachesto
assessment,careand
treatment

220patientswere
SPSS12software
identifiedbythestaff
orthroughpatientcare
records

Facilitiesauditusing
informationfromclinicalnurse
leadersandcontinencelink
nurses

Toreviewclinicalareas
forfacilitiessuchas
toiletfacilities,staff
continenceeducation
programmes,accessto
continenceaids,etc.

Two40bedunits
(site1)andfivewards
andonedayhospital
(site2)

SPSS12software

Staffknowledgequestionnaire
(Irwinetal.2001)distributedto
nursing,medicalandtherapy
staff(58atsite1and96atsite
2)

Toassessstaff
knowledgeabout
managementof
continence

97questionnaires(44
fromsite1;53from
site2

SPSS12software

Observationsofpractice(non
participant)withasemi
structuredinterviewschedule,
developedusingtheEssenceof
Care(DH2001b)continence
benchmarksandManleys
culturalindicators(2000a)

Tofocustheobservation
ofbestpractice

Totalof16hoursof
observationineach
studysite(2hour
periodsatdifferent
timesoftheday)

Tenstagethematic
(Elyetal.1991)and
characteristicsof
contextfromthe
PARIHSframework

Focusgroupsdiscussions
betweenmultidisciplinaryteam
members,carriedout(after
analysisofdatacollectedinthe
previousstages)andusing
Manleysculturalindicators
(2000a)asabasis

Toexplorethecontextof
continencepractices
withintheparticipating
unitsandtodiscussin
depthalldatacollected
duringobservationsof
culture

Sixfocusgroupswith
totalof26MDT
members(twogroups
insite2andfourin
site1)

Tenstagethematic
(Ely1991)merged
withpreviousdata
withinthecontext
framework

Finalanalysisusingthecontextframework
Thefinalstageinvolvedanalysisofalldatawithinthecontextframework,fromwhichwecouldidentifythestrongandweak
characteristicsofthecontextwithinwhichcontinencecarewasprovidedateachsite.Thedatawereconsideredinthreegroups
culture,leadership,andevaluationandcharacteristicswereassignedalongacontinuumofweaktostrongevidence(strong
evidenceenhancespersoncentredcontinencecare,andweakevidencehindersit).
Table3showshowcommentswereusedtocreatethestatementsintheCAI.Table3usesanextractfromthecontext
frameworkandillustratesthecharacteristicsofdecisionmaking.

13

Table3:Exampleofstatementdevelopment
LACKOF
APPROPRIATENESS
AND
TRANSPARENCY

Dataextracts

APPROPRIATEAND
TRANSPARENT
DECISIONMAKING
PROCESSES

Lackof
understandingfor
therationalfor
decisionsonthe
careand
managementof
continence

RCPaudit:nodiagnosisofcontinenceproblemsmadefor74%of
patients.85.6%hadbodywornpadswithnostatedrationaleforthis
approachtocontainmentofcontinence

Clearrationalforall
aspectsofcontinence
care,management,
treatment,etc.

Lackofappropriate
decisionsonthe
approachto
continence
promotionandcare
Lackofinvolvement
oftheolderperson
inthedecision
makingprocess
Staffnotproviding
arationalfortheir
actions
Approachto
continencereactive
Themanagement
structurenotclear
Nomembersofthe
multidisciplinary
teamor
management
having
responsibilityor
accountabilityto
ensurepatients
receivebest
practicecontinence
care

Document:'Alldatatodatetogether';10passages;1713characters
Section0;Paragraph14;116characters:Noplanningpriorto
commencingpatientcare;unclearhowthenursesknewwhichpatients
neededorwantedcarefirst.
Section0;Paragraph113;23characters:Noprioritisingofwork.
Section0;Paragraph151;225characters:Assessmentofcontinence
statedwhetherthepersonwascontinentorincontinentbutnoother
detailsofcauseorpatientperception.Theassessmentfollowthis
appearstobeinternaltothenurseandisabouthowtomanagethe
continencenothowtopreventoreducate.
Section0,Paragraph171,442characters:Workedbasedonroutineand
ritualssuchasnoplanforhowtheywouldworkjustgotonwithcarein
thesamewayasalwaysdo(i.e.didnotdiscussifapatientneededtheir
positionchangedfirstorpadchangedorofferedthetoilet).Asnoneof
thisinformationwasgivenathandoverthennowayofknowthe
patientsneedsforthosewhodidnotarticulatetheircare.Didnotknow
whattimepatientswenttobedorlasthadofferoftoilet.
RCPaudit:In97%ofcasespatientshadhadnodiscussionregarding
theircontinence.
Focusgroup:Wewouldlookatitfromadifferentperspective
(assessment)inthatwhenapatientisreferredtouswewouldgotothe
wardanddoaquestionnairewiththemandfindoutwhattheir
incontinencewaslikepriortoadmissionbecausesometimestheymay
ormaynotbeenincontinentalreadyandmaybeseehowthataffected
themandtheirfunctionbeforeadmission.Wewouldusuallyaskifthey
hadproblemswithincontinenceandhowthataffectedthem.

Continencecare
basedonan
assessmentwhich
providesa
comprehensive
pictureofthepatient
Evidenceof
assessment,planning
andevaluationbased
onmultiple
approaches,
observation,
interview,etc.
Documentedevidence
ofproactive
promotionand
managementof
continence
Clearandopen
channelsof
communication
betweenclinicaland
nonclinicalstaff
Sharedresponsibility
andaccountability
withintheteamfor
providingbest
practicecontinence
care

14

SECTION5
Phase1:Findingsfromanalysis
ThissectionpresentsasummaryofthefindingsfromananalysisofthedatacollectedinPhase1.

RoyalCollegeofPhysicians(RCP)auditscheme
Themeanageofpatientparticipantsacrossbothsiteswas80years.Theaveragelengthofstaywas25daysin
site1and35daysinsite2witharangeof1150days.Oftheparticipantsinbothsites,60%hadurinary
incontinenceonlyand3%hadfaecalincontinence.Frequencyofincontinencewasoncedailyfor62%of
participantsatsite1anduptothreetimesdailyfor70%atsite2.

Urinaryincontinence
Thiswasassessedfromexistingdocumentationandfromincontinencechartsin61%ofpatients.Investigations
ofcausationatsite1includedabdominalexaminationin50%,midstreamspecimenofurine(MSU)in45%,and
residualurinemeasurementin24%.Mostofthepatientsatsite1(89%)werereferredforfurther
investigationssuchasbladder,pelvisorkidneyultrasound,urinalysisandcytology,buttherewasno
documenteddiagnosisofincontinencein45%ofthese.Investigationsatsite2includedMSU(in33%).Only2%
werereferredtoanursingormedicalspecialist,andcontinencechartswereusedforjust9%.
Patientswereaskedaboutcontributoryfactorstotheirincontinenceandmostcitedphysical(64%)ratherthan
environmentalfactors(19%).Documentationrevealedmosttreatmentwasforconstipation(47%)andurinary
tractinfection(43%),with8%receivingmedication.Notsurprisingly,84%(site1)and89%(site2)ofpatients
remainedincontinentaftertreatment.Incontinencewascontainedusingbodywornpads(50%)andtimed
voiding(57%),with87%ofpatientsatsite2usingbodypads.Accordingto62%(site1)and97%(site2)of
participants,urinaryincontinencewasnotdiscussedwiththemortheirsignificantother.Patientswereasked
whethertheyweresatisfiedwiththeirtreatmentand66%respondedtheydidnotknowpossiblyindicatinga
lackofinformationorconfusionabouttreatment.Therewasnodocumentaryevidenceoffollowupin85%of
cases.

Faecalincontinence
Faecalincontinencepresentedclinicallyin54%(site1)and60%(site2)ofpatients,asbothlooseandformed
stools.Thefrequencyofincontinencewaslessthandailybutmorethanweeklyfor54%(site1)and61%
(site2).Atsite2,71%ofparticipantshadexperiencedproblemsforover1month.Assessmentwasmadefrom
generalnursingnotesormedicalnoteswithfaecalendofbedcharts.In82%(site1)and86%(site2)therewas
nodocumenteddiagnosisoridentifiedcauseforfaecalincontinence.Patientsweremanagedbydifferent
interventions,sometimesmultidisciplinary,suchasadvisingontheuseoflaxatives,dietarychanges,
preventionofconstipation(11.5%)andantibiotictreatment.In77%(site1)and89%(site2)continence
problemspersistedaftertreatment.Furthertreatmenthadbeenplannedfor66%(site1)and87%(site2)of
patientsbutwasnotdiscussedwith62%(site1)and72.5%(site2).

Urethralcatheters
Urethralcatheterswereinplacein30%(site1)and27%(site2)ofparticipants.Inmostcases,thecatheterwas
insertedbeforeadmissiontotherehabilitationunit,butin75%therewasnorecordofthedateofinsertion.
Informationin75%ofthewrittenrecordswasprovidedbydoctors.Catheterisations(mostlyclosedsystem
types)wereusuallyperformedpostsurgicallyorbecauseofanacuteorworseningmedicalcondition(71%),
andinmostcaseswerenotintendedforlongtermuse.Recordsofbagemptyingwereavailablein98%of
casesatsite1butonly49%atsite2,andgeneralmanagement(e.g.bagemptying)wasusuallycarriedoutby
thewardnurse(67%).92%ofcarerswerenotusuallyinvolvedincathetermanagementortrainedincatheter
care.

Facilityaudit
ThiswasconductedatbothunitsusingtheRCPauditscheme,withtheassistanceofclinicalnursemanagers.At
site2,theclinicalnursemanagersreportedthatwrittenguidelinesregardingincontinencemanagementwere
availabletostaffontheunit,andthesewerevisibletotheresearcheratthetimeofaudit.Mostofthe

15

stipulatedguidelinesintheRCPaudittoolwerepresentintheunit,withsomeexceptions(e.g.guidanceon
indicationsforreferraltourodynamicassessment,oramedicalorsurgicalspecialistoracontinencenurse
specialist).Atsite1guidelineswerenotavailable.Theclinicalnursemanagersatbothsitesconsideredtoileting
facilitiestobeadequateandconducivetocontinencepromotionandmanagement.
Theauditdemonstratedalackofspecificcontinenceassessment,documentationandspecificrationalefor
treatmentdecisionsorcontinuationofcare.Furthermore,thefocusatbothsiteswasoncontinence
containmentratherthanproactivemanagement.Patientreferralforspecialistdiagnosisandtreatmentwas
limited.Theoutcomeformostofthepatientsfollowingtreatmentwasthattheyremainedincontinent,and
manyreportedthatincontinencewasnotdiscussedwiththem.

Staffknowledgequestionnaire
Thesefindingsprovidedevidenceofactualknowledgeaswellasperceivedknowledge.Forexample,100%and
95%ofstaffcorrectlyansweredquestionsaboutthecorrectmeaningoftheterms'residualurine'and
'hypotonicbladder',56%knewtheaveragebladdercapacityofanadultand67%knewthatresidualurine
couldbeexpectedwithahypotonicbladder.AstudyofstaffknowledgeconductedbyIrwinetal.(2001)
showedthat97%knewpelvicfloorexercisescanimprovestressincontinence;inthepresentstudy,100%knew
thisfact.Incontrast,only37%inthepresentstudyknewthatanticholinergicdrugscouldbeusedtotreaturge
incontinencecomparedto44.6%inIrwinsstudy.Bothstudiesrevealedsimilar(good)levelsofknowledge
regardingcontinencepromotionandprevention.Forexample,74%knewthatreducingcaffeineintakecould
reduceurgencyandfrequency,and63%knewthatdietaryvitaminChelpspreventencrustationoflongterm
catheters.Theresultsdemonstrateahighlevelofperceivedandactualknowledgeaboutcontinenceandits
managementamongstaffwithinthemultidisciplinaryteaminbothstudysites(asevidentfrompreviously
collecteddata).

Observationofpractice
DatawererecordedonanobservationscheduleusingtheEssenceofCarebenchmarkingframeworkfor
continencecare(DH2001b).Thisevaluatedtheobservedcareagainstelevenbenchmarksforevidencebased
continencepractice,scoringobservationsonacontinuumfromA(bestpractice)toE(worstpractice).Scores
wereanalysedusingEssenceofCare,andwerethengroupedintothetwoculturalthemesdevelopedby
Manleypatientindicatorsandstaffindicators(Manley2000a,b).
Observationaldatawerethenanalysedindepthusingthetenstepapproachtoqualitativeanalysis(devisedby
Ely1991andlateradaptedbyMcCormack2002).Initialimpressionswerenotedandalistofsubthemeswas
drawnup.Thesesubthemeswererevisedandrefinedandnarrativewasselectedtolinkwiththesubthemes.
Themestatementswerethenwritten,basedoncommoncharacteristicsofthesubthemes.Allfindingswere
comparedforpatterns,commonalities,differencesanduniquehappenings.
Atsite2,theobservationaldatasuggestedthepresenceofstrongenablingfactorsregardingcontinencecare
(e.g.nurseswereobservedrecordingbowelmovementsontheendofbedchartsusingtheBristolstoolscale).
Patientshadeasyaccesstotoiletfacilitieswithinthesixbeddedbay,anddidnotwaitforlongfortoileting
assistancefromthestaff.Theatmospherecreatedbythestaffwasconducivetopatientcomfortandrequests
forassistancewereneverleftunanswered.Staffdemonstratedfamiliaritywiththeirpatientsandgoodrapport
withalldisciplines.Therewasevidenceofteamworkandcollaborationbetweendisciplines:anurseand
physiotherapisthelpedonepatienttowalktothetoilet,encouragingherallthetime;onepatient,newly
returnedfromphysiotherapy,washelpedtothebathroombythephysiotherapist,reassuringhimthatitwas
closebyandthathecouldmakeit
Site1wassimilarinsomewaystosite2,butatothertimestheneedsofthewardareawereputbeforethe
needsofthepatients.Forexample,thelightswereswitchedonat07.30AMandthestafftalkedloudly,
seeminglyunawareofthepatients'needforrest.Patientdignitywasnotconsistentlymaintained:onenursing
auxiliaryaskedapatientwhowasonthetoiletiftheyhadfinished,openingthetoiletdooreventhoughother
peoplewerepresent.
Inbothsitestherewaslittleobservedevidenceofinvolvingpatientsindecisions;nonewereofferedanychoice
abouttheircare.Theprevailing'culture'wasofthepatientsbeingdoneto,havingonlyapassiverole.Atno
timeduringcaredidnursesrefertothepatientsdocumentation.Dignitywasnotalwaysaprimeconcern,and
thereweresomeroutineandritualisticpractices.Bothunitswereacknowledgedtobeverybusy,withhigh
turnoverofpatients.Somestaffindicatorswereidentified,includingproactivityofstaffdedicatedtopatient
wellbeing.However,lackofleadershipandmanagement,particularlyinrelationtocontinencecare,was

16

evident,andleadershipandtheorganisationofcarevaried.Inoneward,thenursescaredforonegroupof
patientsforthewholeshiftbutinanothertheyonlycarriedoutpersonalcarehencenoonehadspecific
responsibilityforthefollowthroughofcare,andsomepatientsdidnotreceivethecaretheyneeded.The
managementofincontinenceappearedtobethesoleresponsibilityofthenursesand,althoughteamworkwas
evidentinareassuchasmobilityandnutrition,itwasnotseeninthemanagementofpatientswithcontinence
problems.Nurseswereobservedgettingthepatientswashedanddressedfortherapy.Ifanypatientsaskeda
therapisttotakethemtothetoilet,theyrequestedanursetodothis,eveniftheythenlatermobilisedthe
patient.

Focusgroups
Thethemes(andidentifiablegaps)thatemergedfromanalysingthismaterialformedatopiclistfordiscussion
bythefocusgroups.ThetopicsareoutlinedindetailinAppendix2.Whendiscussing'evidenceofcontinence
management',membersgavetheiropinionsonhoweachunitperformedinanumberofareas,suchasspecific
continenceassessment,clearrationalefortreatment,consistencyandcontinuityinapproachestocontinence
management,andevaluationofcare.Discussionofthetopic'patientindicators'includedhowinformationand
choicewereprovidedforpatients,howdignitywaspromotedandwhetheranyimprovementscouldbemade.
'Staffindicators'involveddiscussionofthepriorityofknowledgeandskillsincontinencemanagementwithin
theteam.Memberswerealsoinvitedtodescribetheirownrolesincontinencepromotionandmanagement
andtoassignresponsibilityforleadershipincontinencecare.
AnalysisofthefocusgroupdatawasconductedinitiallyusingtheEly'stenstepguide.Theemergingthemes
werematchedtothePARIHScontextframeworkdevisedbyMcCormacketal.(2002).Individualquoteswere
chosentodemonstrateeitherstrong(enabling)characteristicsofcontextorweak(hindering)characteristics,
undertheheadingsoutlinedinthePARIHSframeworkcontext,culture,leadershipandevaluation.
Thereappearedtobelackofclarityofprofessionalboundariesincontinencecare.Itwasproposedbyone
member,forexample,thattoiletingisusuallyanursingfunction.Nursesreportedthattherapistscometo
themifpatientswantedtogotothetoiletorthattherapistsbroughtthembackfromtherapydepartmentsif
theyhadbeenincontinent.Thisclearlycausedtensionbetweenthenursesandtherapists.Onetherapiststated
'assoonasweget[tothetherapydepartment]theywantthetoiletandthateatsintothetherapytime'.
Membersalsocommentedontheinappropriatenessoftoiletingequipmentinopenplanwards,and
highlightedthedifficultiesofcarryingoutcarewhenfamilyandfriendsarevisiting.Issueswereraised
regardingtheroutinepracticeofpatientsbeingtransferredtotheunitwithcontinencepadsinplace.
Onthewhole,membersfromsite1weresatisfiedthattheyhadrecentlyintroducedanewcontinence
assessmenttool.Howevertheyfeltpowerlesstoenhanceservices,citingtheneedfortheappointmentofa
continencespecialist.Frustrationaboutlackofresourceswascommon,inadditioninsufficientinformationfor
patientsorstaff.Educationaboutcontinencecareandmanagementwassuggestedforallstaffontheunits.
Stafffelttheydidnotknowenoughaboutcontinencepromotionandtreatments.Atsite2,staffacknowledged
thatcontinenceassessmentwasnotroutinelycarriedoutandthereforeneededimproving.Acontinencenurse
specialisthadbeenappointedatsite2butherrolewasnotreferredto.
Themultidisciplinarymembersappearedtobereceptivetochangeincontinencecare,agreeingthat
continenceisnotseenasapriorityandthattheenvironmentinwhichtheyworkedwasnotaltogether
conducivetopersoncentredcare.Thelackofspaceforpersonalcareandpatientprivacywashighlighted.
Althoughthefocusgroupmembersadvocatedteameffort,thereweresomeinconsistenciesinpractice.At
site1,physiotherapistsandoccupationaltherapistsinthegroupfeltthatcontinencecarewasbeyondtheir
remit.Atsite2,however,itwasfeltthatcontinencewaspartofthetherapist'sremitbuttherewasuncertainty
aboutthetherapist'srole.Itwasagreedthatphysiotherapistscoulddomorebypromotingpelvicfloor
exercises.
Includingpatientsinowntheircarewasseenasimportant,andallmembersworkedontheprincipleof
inclusionandthepromotionofselfcare.However,atsite2thestaffacknowledgedthatolderpersonswere
oftennottreatedlikethis,andthatitwastooeasytorelyonpads.Onetherapiststated'Idontthinkwedo
enoughnow,justgetthepadsanddontaskwhattheyknow'.Continenceassessmentwasmentionedbut
therewaslittlementionofevaluation,eventhoughonemembercalledforanauditofpractice.
Thefocusgroupdiscussionhighlightedtheneedforfurthercollaborationbetweendisciplinesinorderto
enableproactivecontinencecare,aswellasaneedfortheempowermentandinvolvementofpatientsintheir
continencecareandleadershipofpractice.Themultidisciplinaryteammembersdisplayedstrongawarenessof
thedeficienciesinthepracticeofcontinencecareandmanagementandofthechallengesahead.

17

Finalanalysisusingthecontextframework
Thefinalstagewastoanalysealldatawithinthecontextframeworkinordertoidentifystrongandweak
characteristicsofthecontextwithinwhichcontinencecarewasprovidedinthesetwosites.Datawerethemed
undertheelementsofculture,leadership,andevaluation,andeachcharacteristicwasratedalongacontinuum
ofweaktostrongevidence(strongevidenceenhancespersoncentredcareandweakevidencehindersit).
ThisprocessisillustratedinTable4withanextractfromtheelement'leadership'andthecharacteristicof
'didacticapproachestolearning/teaching/managing'alongthecontinuumtothestrongcontextof
'enabling/empoweringapproachestoteaching/learning/management'.
Table4illustrateshowthedatawereorganisedwithineachofthecharacteristics.Inthisexample,mostdata
fellattheweakendofthecontinuum,reflectingadidacticapproachtolearning/teaching/managing.Although
therewaslimitedevidenceof'enablementandempowerment',thestaffatthefocusgroupsgaveexamples
whichsuggestedtheyhadsomeinsightintotheexistingdidacticapproach(suchas:'Ithinkthatweshould
sharemoreandlearnmorefromeachother.Newideascomeandgoandthatsthat,butwecouldlearnaswe
allknowalot').Thethreeelementsofcontextandthecorrespondingcharacteristicsidentifiedwithinthe
PARIHSframeworkcapturedalltheaspectsofcontextwithinthestudy,someofwhichoverlappedandwere
thereforeamalgamated(seeIntroductioninSection6).
Theelementcontextwasremovedandthecharacteristicsdistributedwhereappropriatewithin'culture',
'leadership'and'evaluation'.
Thetrendthroughouttheanalysiswasthatthedatasupportedaweakcontext.Verylittlewasatthestrong
endofthecontinuum.Appendix3containsvariousexamplesofthedatathatillustratetheuseofthecontext
frameworkfortheanalysis.

Discussion
Thedataillustratethatpractitionershadsomeinsightintothecontextualfactorshinderingorenhancing
evidencebasedpractice.However,duetoacultureofunclearbeliefsandvalues,andleadershipthatreflected
anautocraticapproach,theyfeltdisempoweredtochangetheirpractice.ThisisillustratedinTable4wherethe
leadershipwasmoreautocraticthan'transformational'.Withouttransformationalleadership,teammembers
wereunabletooptimisetheirskills,abilitiesandknowledge.Thestaffshowedtheywereawareofthelimiting
affectofautocraticleadershipontheirabilitytoelicitchangesincontinencepractice.
Theapproachtocontinenceproblemsreflectedreactivecontinencecare,withlimitedassessmentsandover
relianceontheuseofpadsandpantsasfoundwithintheliterature(Blandetal.2003,Gray2003).Continence
problemswereseenasanacceptedpartofaging,leadingtonurseslosingsightofthesignificanceof
continenceinrehabilitationofolderpeople.
Themultidisciplinaryteamwereawarethatthereweredeficienciesintheircareandmanagementof
continenceandofthechallengesahead.Onepersonexpressedthis:'Wecoulddopatienttrainingasagroupto
helpthepatientsunderstandcontinence.Dontthinkwedoenoughnow,justgetthepadsanddontaskwhat
theyknow'.Theyagreedthatcontinencewasnotgivenahighpriorityandthattheenvironmentinwhichthey
workedwasnotaltogetherconducivetopersoncentredcare.Measuringpracticebyusingharddata(e.g.
lengthofstay)andsoftdata(e.g.patientfeedback)werenotpartofthe'culture'.Withoutthesedatatoinform
theirpractice,staffwereworkinginavacuumandwereunabletounderstandhowtheycouldimprovethe
patients'experiences.
Alongsidethis,therewerenoopportunitiesforreflectingonpractice,inaculturewherepracticewent
unchallenged.Therewasarelianceonclassroomteachingbut,astheliteratureontheproblemsofgetting
evidenceintopracticeillustrates,providinginformationalonedoesnotchangepractice(RycroftMaloneetal.
2002).Thedatareinforcethesignificanceofunderstandinganddevelopinglocalcontexttoenablethe
provisionofpersoncentredpractice.Becausethestaffdidnotunderstandtheimpactthatthecontext
(leadership,cultureandevaluation)washavingontheirpractice,theycontinuedtofeeldissonancebetween
howtheypracticedandhowtheywouldliketopractice.Therefore,theywereunabletoputtheirespoused
beliefsandvaluesintopractice,leadingtoaculturethatwasnotreceptivetonewideasandwaysofworking.
Practicecontinued,therefore,tobetaskbased,withlimitedchoicegiventoolderpatients,andalowregard
forpatientprivacyanddignity.

18

Table4:Extractfromdataanalysiswithinthecontextframework
DIDACTIC
APPROACH
TO
LEARNING/
TEACHING/
MANAGING

Dataextracts

ENABLING/
EMPOWERING
APPROACHTO
TEACHING/
LEARNING/
MANAGING

Classroom
based
teachingand
education

Section0;paragraph16;123characters

Developmentof
practicefrom
withintheteam
aswellas
outside

Basedona
narrowform
ofknowledge
Noreflective
practice
Hierarchical
learning
(beingtold
whatto)
Practicenot
evidence
based
Limited
prioritygiven
tolearning
Issuesremain
unsolvedand
nofollow
through
Blameculture
Limited
insightinto
theirown
learning
needsor
thoseofthe
unit
No
questioningof
practice
Controlof
patients
decision
making

LLimitedintroductionstopatientsbythestaffbycaredelivery.The[nursing
assistant]workedunsupervised,thereforenolearningofcontinencecouldtook
place.Therewereplentyofopportunitiesforpatienteducationbutnonetaken.
EvenwhenpatientaskedWhataremytabletsfor?thepatientwasnottold.
Patientcomment:'Cantheytreatit?Ithoughttherewasnothingtheycoulddo.'
Observation:'Iwastoldtheyusedtohaveleafletsforpatientbutnooneread
themsowetookthemdown.
Focusgroup:'Ifyouwanttoknowsomethingyouask,andsisterorsomesenior
tellsyouthatshowitisandthatshowwelearn.Youlearnbywatchinganddoing,
followingothers'.'Huh.Theydontdiscussanythingandnotprivatethingsanyway.
Cantheydosomething?IweartheseherepadsbutthatmeansIcantgettothe
bottlebutIdontwearthepadsIwetmyself.Cantheydoanythingelse?Itshows
there,mytrousersandall.'
Focusgroups:'Inservicetraining(iswherenewideascomefrom).Someonegoes
onacoursethenbringstheinformationback.Thereisalotoftrainingneeded
whichhascomeoutofdevelopingtheMDTnotes.Oneayearinservicestrainingas
staffchange';'Linknursesshareinformationwithusallthenwecanputitinto
practice';'Welearnaboutcontinenceonthejobaswegoalong.Wehavenoformal
teaching';'Whenapatientsaystheydontwantthetoiletyousay"Comeonand
try"astheyusuallydoneedit';'Ifyouwanttoimplementchangeyougothrough
sister.Itisherdecisionthenifithappens'.
RCP:Noprotocolsorguidelinesoncontinenceinonesite.
Focusgroup:'Wecoulddopatienttrainingasagrouptohelpthepatients
understandcontinence.Dontthinkwedoenoughnow,justgetthepadsanddont
askwhattheyknow.'
Observation:Staffconstantlycheckingwiththepatientthatwhattheyaredoingor
sayingisunderstoodandexplaininganactivityoradelay.
Focusgroup:'Sometimes[thepatients]aresaying"Ihadbeencallingandcalling
andnobodycame"whichcanhappenattimesoneveryward,butIjustwonderare
thingsasregularandifpeoplearebeingapproachedasregularastheywouldliketo
be?';'Ithinkthatweshouldsharemoreandlearnmorefromeachother.New
ideascomeandgoandthatsthat,butwecouldlearnasweallknowalot'.

Drawson
differenttypes
ofknowledge
(craft,
propositional,
etc.)
Basedon
evidenceof
bestpractice
Learningtakes
placewithinthe
workplace
through
reflectioninand
onpractice,
supervisionand
actionlearning
Leadersrole
modelling
Noneblame
culture
Facilitative
approach
Knowledgeand
skillsofpractice
development

Observation:Nurseistakingthetimetoorientatethepatientsaboutthedate,day
andtimeinformally.Nursehasspokentooneofthepatientsregardingtheuseof
hipprotectorsandhasofferedtoarrangetheprocurementoftheseforthepatient
withaphysiotherapist.
Focusgroup:'Regularupdatesforstaffandstudentsarenecessary.Likeallsciences,
itsamovingentityandadvancesarebeingmade.'
Observation:Aphysiotherapistdiscussinganexercisewithoneofthepatientshe
introducedherselfandherroleandthenproceedstoencouragethepatientto
followtheexamplesheprovidesofcarryingouttheexercisesneededtoimprove
hisarm.Apatientasksoneofthenursesaboutachiropodyservicesheis
informedpromptlyabouttheavailabilityoftheserviceandofferedareferralif
required.

19


Conclusions
Usingcontextframeworktoanalysethesedataprovidedapictureofthecontextwithinthesetwounitsandits
significanceinhinderingorenhancingevidencedbasedcontinencecare.Evidencesuggeststhatthecontext
wasweakandnotconducivetopersoncentredcontinencecareandmanagement.Clearlydevelopmentwork
isneededtocreateacontextthatreflectsstrongleadership,cultureandeffectiveevaluation.
Thefindingsreflectthosefoundwithinthereviewedliterature,anditcouldbearguedthatthismighthave
beenachievedwithoutusingthecontextframework.However,byusingtheframeworkwewereableto
identifyspecificcontextualissuesthatwerehinderingandenablingthedeliveryofpersoncentredcare.The
themesthatarosefromthisprocess(illustratedinTable4)weredevelopedintostatements,andthese
statementswerethefoundationfordevelopingtheContextAssessmentIndex.

20

SECTION6
Phase2:DevelopingandtestingtheContext
AssessmentIndex(CAI)
Introduction
Thefirststagewasthedevelopmentofstatementsfromtheanalysisofdatawithinthecontextframework.
Statementswerebothnegativeandpositive.Theywerelistedintheoutsidecolumnofthecontexttable,and
eitherreflectedastrongcontextoraweakcontext(asillustratedinTable4).Thewordingofthestatements
neededtoreflectthattheCAIwasaselfreportingtool,whichaimedtoobtaininformationofpractitioners'
personalviewsandexperiencesoftheirworkbasecontext.Therefore,thestatementsneededtobeas
unambiguousaspossible.Thesecondstageneededpractitionerstoidentifyaconnectionbetweenwhatthe
statementwasaskingandtheirownworksituation.Forselfreportedtools,thestatementsmustberelevantto
thoseusingthetool(Babbie1989).Respondentsalsoneededtobeabletoreadthestatementsquicklyand
graspwhatwasbeingaskedofthem.Finally,itwasnecessarytoensurethatthestatementsarosedirectlyfrom
thedataandreflectedtheaimoftheCAI(Babbie1989).
Therewassomerepetitionintheinitiallistofstatementsobtainedforeachofthecharacteristics.Therefore,
threeofthecharacteristicswereamalgamated:

'Informationandfeedback'fromcontextwasmergedwith'feedbackonindividualteamsandsystems'in
'evaluation'.

'Promoteslearningorganisation'wasmergedwith'effectiveorganisationalstructure'.

'Autocraticdecisionmaking'wasmergedwith'traditional,commandandcontrolleadership'.

Theextensivelistofabout300statementswasreviewedbytheprojectteamtoeliminatestatementsthat
wereclearlyrepetitiveforeachcharacteristic.Theyreducedthelisttoabout88statements.Itwasdecidedto
useafourpointLikertscale(Likert1952)usingtheheadingsofStronglyagree,Agree,Disagree,and
Stronglydisagree.ItwasdecidednottouseastatementsuchasDontknowinordertofocustheuseron
agreementordisagreement.Bothnegativeandpositivestatementswereused.
Phase2wasconcernedwithdevelopingtheCAIthroughtestingthevalidity,reliabilityandusability.Thiswas
undertakeninfourstages:

Prepilottestingforcomprehensivenessandspecificity.

Pilottestingforfaceandcontentvalidity.

Largesampletestingforfactoranalysispurposes.

Testretestforreliability,stabilityandhomogeneity.

Usabilitytestingviatelephoneinterviews.

Prepilottesting
Theaimoftheprepilotwastotesttheclarity,specificityandcomprehensivenessoftheCAI.Wewantedto
gainfeedbackonwhethertheuserunderstoodwhatwasbeingaskedofthembyeachstatement(clarity),
whetherthestatementsreflectedeachofthecharacteristics(specificity),andwhethertheCAIcoveredall
elementsandcharacteristicsofcontext(comprehenisiveness).Theinstrument(seeAppendix4)wassenttoten
continencenursespecialiststhroughouttheUKandIreland,eightofwhomarerecognisedexpertsinpractice
development,identifiedthroughtheRoyalCollegeofNursingcontinencespecialistmembersforum,the
AssociationofContinenceAdvisors(ACA)andtheNationalCouncilfortheDevelopmentofNursingand
MidwiferyDatabase.PracticedeveloperswereidentifiedthroughtheUKDevelopingPracticeNetwork(DPN).
Thesenursesweresentacopyofthefirstdraftoftheinstrumentandafeedbacksheet.

21

Results
Eightcontinencenursesandsixpracticedevelopmentnursesreturnedthefeedbacksheet.Thefeedbackwas
groupedtoidentifythreethemes:clarityofthestatements,layoutoftheCAI,andclarityofterminology.This
feedbackwasconsistent,highlightingstatementsthatwereunclearandambiguous(e.g.whowasreferredto
bythetermsmanagerorhealthcareprofessional).Theyrevealedrepetitioninsomestatementsforeachof
thecharacteristicsfromthecontextframework.TheCAItook20minutesonaveragetocomplete,whichthe
prepilotgroupfeltwasacceptable.Therewerenocommentsaboutthefactthatonlyfourpossibleanswers
wereofferedforeachstatement.FeedbackwasverypositiveaboutthevalueoftheCAIintheclinicalsetting
andrespondentsfeltthatitwasverycomprehensive.
RevisionswerethenmadetotheCAI.Somestatementswereremovedandsomelanguageclarified.Alistof
abbreviationswasaddedtoexplainkeyterms.AtthisstageaguidewasalsodevelopedforusewiththeCAI(to
betestedlateroncetheCAIhadbeendeveloped).Theinclusionoftheelementof'context'wasconfusing
becausetheoriginaldescriptionoftheframework(Kitsonetal.1998)isthattheelementsare'partofcontext'.
Theprojectteam,therefore,decidedtoremovetheelementof'context'andtoamalgamatetheindicators
withincontextintothreeotherelements(culture,leadershipandevaluation).
Theelementheadingsthatindicatedwhichcriteriarelatedtothe'culture','leadership'and'evaluation'were
removed.Statementswerethenreordered,bytakingonestatementfromeachcharacteristicinturn,sothat
peoplecompletingtheCAIwouldnotknowwhichcharacteristicthestatementswerereferringto.

Pilottesting
ThisaimedspecificallytotesttheclarityofeachitemoftheCAI.Ateachstudysite,theresearchersdiscussed
theuseoftheCAIwithatotalof16continencelinknurses,whothencompletedafeedbacksheet(Appendix5)
abouttheclarityoftheCAIandgaveoverallfeedback.Sixpracticedevelopmentexpertswerealsoaskedfor
feedback,includinganyqualitativecomments.AnalysisofthisfeedbackallowedfurtherrevisionsoftheCAI.

Results
MoreclarificationwasneededaboutsomeofthestatementsintheCAI.Thenursesstatedthattheyfeltthe
CAIwouldbeofvaluetoimprovingpractice.Onestated:'Itmakesyouthinkaboutwhatyoudoandhowyou
candoitbetter.Itistherefore,agoodtoolforreflectingonpractice'.However,thecontinencenursegroups
feltthatexpectingnursestoachieveallstatementswasidealistic.Thepracticedevelopmentnurseshadminor
suggestionsaboutgrammar.AllfelttheCAIwouldbeofvaluebutfeltitwastoolong.Fromthisfeedback,
grammaticalerrorswerecorrected.TheresearchersrecognisedthattheCAIwastoolongandaimedtoreduce
thenumberofstatementsfurtherstill.ItwasalsodecidedtodevelopaguidetotheCAIandinterpretation
processtoaidnurses'reflectionontheirpractice.Itwasplannedtotesttheseatalaterdate.

Largesampletesting
TheCAIwassenttoasampleofregisterednursestotestitsfactualstructure,andwhetherthestatements
reflectedeachelementofthecharacteristicsofcontext(culture,leadership,andevaluation).Registerednurses
wereidentifiedbycontactingalltheDirectorsofNursingwhohadresponsibilityforolderpeoples'services,to
requestinformationontheservicestheyprovided,thenumbersofregisterednursesemployed,whetherthey
wouldlettheirfacilitytakepartofthestudy,andthenameofapersonwhocouldactaslocalcoordinator.The
originalaimwastorecruit500ontothestudy,buttheresponsewasgood,so915nurseswererecruitedfrom
aroundIreland,whoprovidenonacutecareforolderpeopleincommunityhospitals,postacutecare,day
hospitals,strokeunits,andposthipreplacementwards.Atotalof19hospitalswereidentifiedofwhich12
agreedtotakepart,incorporating25wardsandunits.Intotal,436nursesfromNorthernIrelandand479
nursesfromtheRepublicofIrelandagreedtoparticipate,from27differentsites.Thenumberofnursesateach
individualsiterangedfrom557.
TheCAIwassenttothese915nursesviacoordinatorsforeacharea,withintroductoryandexplanatoryletters.
Theparticipantshad1monthinwhichtoreturnthecompletedCAI.Theresearchersphonedeachweekto
checkonprogress.Tables5and6showthetypeofserviceprovidedbyeacharea,thenumberof
questionnairessenttoregisterednursesineachareaandthereturnrate.Intotal,192(44%)werereturnedin
NorthernIrelandand268(56%)intheRepublicofIreland.Thetotalwas460(50.27%).

22

Table5:LargesamplevaliditytestinNorthernIreland
Code

Serviceprovided

Numberofquestionnaires
Sentout

Returned(percentage)

1rehabilitationunitforolderpeople

105

57(54%)

2rehabilitationwardsforolderpeople
1wardforolderpeoplewaitingnursingor
residentialcare

54

19(35%)

Dayhospital
3generalolderpeoplerehabilitation

50

23(46%)

1strokeunit
1dayhospital
3rehabilitationwards

50

2(2.5%)

3continuingcareforolderpeople

40

32(80%)

1rehabilitationwardforolderpeople

35

13(37%)

1strokeunit
1postorthopaedicrehabilitationward

34

1postacuterehabilitation

26

14(54%)

1postorthopaedicrehabilitationward

24

11(46%)

10

1generalrehabilitationwardforolderpeople

18

TOTAL

436

192(44%)(Misc.21)

Results
AnalysiswasconductedfollowingtheprocedureoutlinedbyKline(1994)withtheobjectiveofreducingthe
numberofitemstoreflectastrongfactorstructuring.Principlecomponentsanalysiswascarriedoutonall
itemstoidentifythenumberoffactorsinthequestionnaire.The83itemsoftheCAIweresubjectedto
exploratoryfactoranalysistoinsurethatthestrongestfactorstructurewouldemergefromthedata.
Maximumlikelihoodwasusedtoextractthefactorstructuresfromthedata.AprocessofVarimaxrotated
extractionwasusedtoensurediscreetfactorstructures.Thisprocessisahighlyanalyticalmethodforobtaining
orthogonalrotationoffactors.Itcentredonsimplifyingthecolumnofthefactormatrixandgaveclearer
separationoffactors(Hairetal.1998).Thenumberoffactorsextractedwassetat20,determinedbyEigen
valuesover1andbasedonthefindingsoftheprinciplecomponentsanalysis.The20factorsthusidentified
explained64.27%ofthevariance.(Interestingly,thenumberoffactorstobeextractedwasleftunspecifiedina
separateanalysis,andthisproduceda20factorsolutionalso.)The20constructswereextractedfromthedata
andcriteriaforitemreductionwerebasedontwoprinciples:

Afactorloading(thecorrelationoftheitemwiththefactor)of0.4wassetusingpoweranalysisbasedon
thesamplesizeandasignificancecriteriaofP<0.05,powerlevelof0.80andstandarderrorsassumedto
betwicethoseofconventionalcorrelationcoefficients(SoloPowerAnalysis,BMDPStatisticalSoftware,
Inc.1993).

Atleasttwoormoreitemsperconstruct.

23

Table6:LargesamplevaliditytestinRepublicofIreland
Code

Serviceprovided

Numberofquestionnaires
Sentout

Returned(percentage)

Rehabilitationunit

12

1(8.5%)

Rehabilitationunit

5(100%)

Rehabilitationunit

43

21(49%)

Rehabilitationunit

3(60%)

Rehabilitationunit

20

19(95%)

Rehabilitationunit

16

7(44%)

Rehabilitationunit

Rehabilitationunit

8(95%)

Rehabilitationunit

12

10(60%)

10

Rehabilitationunit

19

13(68%)

11

Rehabilitationunit

12

11(95%)

12

Rehabilitationunit

25

5(25%)

13

Rehabilitationunit

20

12(60%)

14

Rehabilitationunit

20

14(70%)

15

RehabilitationUnit

11

10(95%)

16

Communityhospital

25

12(48%)

17

Communityhospital

20

13(65%)

18

Communityhospital

25

21(84%)

19

Communityhospital

13

13(100%)

20

Communityhospital

12

6(50%)

21

Communityhospital

30

22

Communityhospital

26

13(50%)

23

Communityhospital

20

9(45%)

24

Communityhospital

20

20(100%)

25

Communityhospital

14

26

Communityhospital

16

6(37.5%)

27

Communityhospital

18

6(33%)

28

Communityhospital

25

7(28%)

TOTAL

479

268(56%)

Usingthisprocess,32itemswereremovedfromtheoriginaldataset,leaving51itemscoveringsevenfactors.
Theitemswerecategorisedintosevenfactorsandtheresearcherslabelledthosefactorsandidentifieditems
withinthemthatwereconsideredmisplaced.Hairetal.(1998)statesthatthisprocedurehelpstoexclude
rogue'itemsfrombeingincludedwithintheoutcomesoffactoranalysis,whichiscommoninquestionnaires
withalotofitems(asisthecasehere).Inthisway,rogueitemswereextractedbeforethenextroundoffactor
analysis.Onefurtheritemwasremovedtoleave50items.

Themodifieddataset(50items)wasanalysedusingmaximumlikelihoodVarimaxextractionwiththenumber
offactorstobeextractedsetto7.Thisprocessreplicatedthefactorstructureofthepreviousanalysis,and
explained52.19%ofthedatavariance.Onlyitemswithfactorloadingsof0.4orhigherwereconsidered
relevanttothefactor.Crossfactorloadingwasincludedintheanalysis.Furtherexaminationofthedataledto
removalofanothertwoitemsandaseventhfactorresourceswasalsodeletedtoleavea47itemedsixfactor
model.

Thesixfactormodelwasdistributedforvalidationwithanexpertpanelof7members(fouroftheprojectteam
andthreeseniorresearchersfromthecollaboratinguniversities)toagreeconstructtitlesanditems.Theteam
wasaskedtoexamineitemswithineachconstructbasedontheirfactorloadingscores,agreethecomposition
ofeachconstructandfinalisethefactortitles.AfurtherFactorwasdeemedasredundantinthatitfailedto

24

explainanythingstatisticallyorprofessionally.Theexpertpanelagreedonafivefactor,44itemmodel(Table
7)withthefollowingcorrespondingfactortitles:
1. CollaborativePractice
2. EvidenceInformedPractice
3. RespectforPersons
4. PracticeBoundaries
5. Evaluation

Table7:Itemsandcorrespondingfactorscoresforthecontextualindicatorsquestionnaire
Items

Testretest
score(%)

Aproactiveapproachtocareistaken

0.52

70%

HCPsandpatientshaveaccesstoappropriatediagnosticmethods
andequipment

0.62

36%

HCPsandpatientsworkaspartnersprovidingindividualpatient
care

0.69

77%

HCPsareempoweredtoinfluenceexternalfactorsaffectingcare

0.48

52%

HCPsprovideopportunitiesforpatientstoparticipateindecisions
abouttheirowncare

0.55

68%

Patientshavechoiceintheassessment,planningandevaluationof
theircareandtreatment

0.61

61%

Patientsareencouragedtobeactiveparticipantsintheirowncare

0.49

64%

FeedbackisatwowayprocessbetweenpatientsandHCPs

0.48

55%

Patientsareencouragedtoparticipateinfeedbackoncare,
cultureandsystems

0.53

87%

OrganisationalstructuresandprocessesarecleartopatientsHCPs
andHSWs

0.48

52%

HCPsintheMDThaveequalauthoritiesindecisionmaking

0.49

59%

Clinicalnurseleaderscreateanenvironmentconduciveto
developmentandthesharingofideas

0.40

68%

Allaspectsofcare/treatmentarebasedonevidenceofbest
practice

0.50

78%

Thedevelopmentofstaffexpertiseisviewedasaprioritybynurse
leaders

0.56

65%

Evidencedbasedknowledgeoncareisavailabletostaff

0.48

83%

Guidelines/protocolsareavailablewhicharebasedonevidenceof
bestpractice(patientexperience,clinicalexperience,research
practice)

0.59

78%

Auditand/orresearchfindingsareutilisedtodeveloppractice

0.48

65%

Resourcesareavailabletoprovideevidencebasedcare

0.57

70%

Educationisapriority

0.55

61%

Theorganisationisnonhierarchical

0.47

57%

Thehospitalmanagementstructureisdemocraticandinclusive

0.40

73%

HCPshavetheopportunitytoconsultwithspecialists

0.48

65%

Nurseleadersactasrolemodelsofgoodpractice

0.44

61%

HCPssharecommongoalsandobjectivesaboutpatients

0.42

87%

Thereisregardforthepatients'privacyanddignity

0.58

57%

Regardisgiventothepatientspsychological/spiritualwellbeing

0.55

52%

Therearegoodworkingrelationsbetweenclinicalandnonclinical
staff

0.53

59%

Staffwelcomeandacceptculturaldiversity

0.41

65%

Decisionsoncareandmanagementareclearlydocumentedbyall
staff

0.46

56%

25

Careisbasedonacomprehensiveassessment

0.47

83%

PersonalandprofessionalboundariesbetweenHCPsare
maintained

0.41

64%

HCPsfeelempoweredtodeveloppractice

0.61

61%

Staffhaveexplicitunderstandingoftheirownattitudesandbeliefs
towardstheprovisionofcare

0.45

55%

HCPsandHSWsunderstandeachother'sroles

0.52

74%

Structuredandopenchannelsofcommunicationexistbetween
HCPs,patients,carersandorganisationmanagers

0.45

41%

Challengestopracticearesupportedandencouragedbynurse
leadersandnursemanagers

0.44

65%

StructuredprogrammesofeducationareavailabletoallHCPs

0.36

65%

Organisationalmanagementisahighregardforstaffautonomy

0.53

65%

DiscussionsareplannedbetweenHCPsandpatients

0.54

59%

Staffreceivesfeedbackontheoutcomesofcomplaints

0.47

57%

Performancemeasures(e.g.staffturnover,lengthofstay)arein
place

0.51

45%

Astaffperformancereviewprocessisinplacewhichenables
reflectiononpracticeandgoalsettingandisregularlyreviewed

0.52

73%

Staffusereflectiveprocesses(e.g.actionlearning,clinical
supervision,reflectivediaries)toevaluateanddeveloppractice

0.62

70%

Appropriateinformation(e.g.largewrittenprint,tapes)is
accessibletopatients

0.48

59%

ThecorrelationmatrixshowstherelationshipbetweenthefivefactorsasseeninTable8.Thisis
unstandardised.

Table8:Correlationmatrixoffivefactorscontainedinthecontextualindicators
questionnaire
Factor

0.56

0.51

0.36

0.38

0.32

0.34

0.29

0.70

0.46

0.30

0.60

0.53

0.21

0.39

0.14

0.23

0.57

0.35

0.58

0.2

0.16

0.21

0.23

0.13

0.8

This44itemmodelwasacceptedasreasonable.Measuresofhomogeneity(seeTable9)werecalculatedfor
eachofthefivefactorstomeasuretheirinternalreliability.Reliabilityreferstotheconsistencyoftheresults
anditisachievedusingCronbachsalphascores.Scoresof0.7aregenerallyacceptable,butincasesofbroad
constructlowerscoresarealsoacceptable.TheCronbachsalphascoreforthecompletequestionnaireis0.93.
Fiveofthesixconstructsachieveasatisfactorylevelofinternalconsistencyinscoring.Thenegativeconstruct
Routinisedcarefailedtoachievetheruleofthumbscore0.7

Table9:Homogeneityofthefivefactorsofthecontextualindicatorsquestionnaire
Constructtitle

Cronbachsalphascores

Factor1Collaborativepractice

0.91(N=13)

Factor2Evidenceinformedpractice

0.88(N=11)

Factor3RespectforPersons

0.81(N=8)

Factor4PracticeBoundaries

0.85(N=7)

Factor5Evaluation

0.78(N=5)

26

Theitemscoresofeachoftheconstructsweresummedforallrespondentstoproducearespondents'
constructscore,anddividedbythenumberofitemstoproduceameanscoreontheconstructforeach
respondent.OverallmeanconstructscoresarereportedinTable10.Scoringrangedfrom1(stronglyagree)to
4(stronglydisagree).Highermeanscoresindicatehigherlevelsofdisagreementwiththefactorthemeasa
contextofcontinencecareandmanagement.Scoresbelow2forbothskewnessandkurtosisindicatean
acceptabledistributionofthescores.

Table10:Meanscoresofeachconstructofthecontextualindicatorsquestionnaire
Constructtitle

Meanscores

Skewness

Kurtosis

Factor1Collaborativepractice

2.28

0.74

1.56

Factor2Evidenceinformedpractice

2.24

0.52

0.92

Factor3Respectforthepersons

1.92

0.26

0.08

factor4PracticeBoundaries

2.05

0.14

0.25

factor5Evaluation

2.50

0.15

0.32

Testretest
Thetestretestwasconductedtotestreliability,stability,homogeneityandconsistencyofthescaleovertime.
Thisinstrumentmustbecompletedbymembersofthesamesampleontwoseparateoccasions,withan
intervalbetweentestsessionstopreventmemoryfrominfluencingtheresults.Aninstrumentisthen
consideredreliableifthesameanswersareproducedonbothoccasions.FeedbackontheCAIwascollected
twoweeksapart.Testretestreliabilityofscorespriortointerventionswerecalculatedbycomparingstability
ofscoresacrossthetwotimepoints.Correlationwasanalysedbylinearregressionwithabestfitlineand
calculationofleastsquaresresidual(LSR).ThecloserthecorrelationandLSRvaluesareto1themorestable
thescoringacrossthetwopoints.
Inthiscaseaperiodoftwoweekswaschosenbecauseitwasconsideredlongenoughforrespondentstoforget
theirinitialanswers,butnotlongenoughforthecultureoftheirorganisationtochangedramatically.Ward
managersworkinginrehabilitationsettingsforolderpeople,whohadbeeninvolvedintheprevioustest
process,werecontactedviatheDirectorofNursingofolderpeoplesservices,andphonedtoclarifytheir
willingnesstoparticipate.The23participantswerepurposivelyselectedaccordingtotheeasewithwhichthey
completedtheinitialquestionnaire,andweredrawnfrombothsites(10fromNorthernIrelandand13from
RepublicofIreland).TheywereinstructedtocompletetheCAIashonestlyaspossibleandtoreturnitina
stampedaddressedenvelopetotheresearcher.ThefirstsamplingwasT1,andtherepeatedsampletwoweeks
laterwasT2.

Results
ThedatawasenteredintoSPSS12foranalysis.Percentageagreementscoresforitems(andtestsofreliability)
werecalculatedusingcrosstabulationsandKendalltaubscores.Constructmeanscoresforbothoccasions
werecomputedandconstructcorrelationscoresweregenerated.Theconstructmeanscoresforallfive
constructswereplottedonasinglegraphandalineofbestfitwasgenerated.Thepercentageagreementfor
itemscoresoftheCAIweregenerallygood.GiventhefourpointLikertscaleofpossibleresponses,therewasa
25%chancethatarespondentcouldrandomlyselectthesameresponseatT2aswellatT1,soanypercentage
agreementgreaterthan25%washigherthanchancealone.All44itemsscoredhigherthanchancealone;two
thirdsscoredhigherthan60%agreement(63%)with30%havingagreementlevelsof70%orhigher;onlythree
scoredlessthan50%agreement.Thepercentageagreementforall44itemswasdisplayedinafrequencytable
ofpercentilesof10%.Thisproducedadistributionof040%(1item,2.27%),4050%(2items,4.54%),5060%
(13items,29.5%),6070%(15items,34%),7080%(9items,20.4%),and80100%(4items,9.1%).Theitem
scoresareshowninTable7.
Theitemsinthequestionnaireformedfiveconstructs.Itemsrelatingtoeachoftheconstructsweremergedto
provideasinglemeanconstructscore,andtheseconstructscoresweretestedfortestretestreliability.
Correlationscoresrangefrom1to+1,where1indicatesaperfectnegativerelationshipand+1indicatesa
perfectpositiverelationship.Anegativerelationshipoccurswhenoneparameterincreasesbyasetunitand
theotherdecreasesbythesameamount.Acorrelation(whetherpositiveornegative)of0indicatesthereisno

27

relationship.Scoresof0.71indicatestrongcorrelations,scoresof0.50.7indicatemoderatecorrelations,and
of0.30.4indicateweakcorrelations.PearsonsproductandSpearman'srhofindingsarebothreported,but
becauseofthesmallsamplesize,prioritywasgiventoSpearmansrho.Thecorrelationsrangedfrom0.38for
'practiceboundaries'to0.82for'evidenceinformedpractice'.Fourofthefiveconstructshadstatistically
significantcorrelationsacrossthetwodatacollectionpoints,withthreehavingprobabilitylevelsofP=0.001.

Table11:CorrelationofconstructscoresattimesT1andT2(*P=0.05,**P>0.001)
Constructtitle
Collaborativepractice

Pearson'sproduct

Spearmansrho

0.29

0.1

Evidenceinformedpractice

0.73**

0.82**

Respectfortheperson

0.60**

0.53**

Practiceboundaries

0.40*

0.38*

Evaluation

0.39*

0.53**

Modificationstothemodel
Toimprovethecorrelationscoresoftheconstructs,itemswithapercentageagreementscoreoflessthan55%
wereremoved.Thereisnohardandfastruleaboutitemremovalsothearbitraryfigureof55%wasagreedon
asastartingpoint.Iffurthermodificationswererequiredtoachievestatisticallysignificantlevelsofcorrelation,
the55%boundarycouldbeincreased.Thismethodidentifiedsevenitemsformodification.

Collaborativepractice
Theconstructcollaborativepracticewasnotsignificantatastatisticallevelandproducedaweakmeasureof
association(0.1).Examinationofitemsinthisconstructrevealedthatfourofthethirteenitemsthatcomprise
theconstructhadpercentageagreementscoresbelow55%andthelowestscoredagreementitem(36%)
relatedto'collaborativepractice'.Thesestatementsabouthealthcareprofessionals(HCPs)arelistedbelow
togetherwiththeirpercentageagreementscores:

HCPsandpatientshaveaccesstoappropriatediagnosticequipment(36%).

HCPsareempoweredtoinfluenceexternalfactorsaffectingcare(52%).

Organisationalstructuresandprocessesarecleartopatients,HCPsandhealthcaresupportworkers(52%).

FeedbackisatwowayprocessbetweenpatientsandHCPs(54.4%).

Theseitemswereremovedfromtheanalysisandthisincreasedthecorrelationscoreto0.43,anacceptable
correlationatastatisticallysignificantlevel.

Respectoftheperson
Theitem'regardisgiventothepatient'spsychologicalandspiritualwellbeing'had52%agreement,andwas
removedfromtheconstructrespectforthepersonandretested.Thisproducedastrongercorrelationof
0.59(SpearmansrhoP=0.000).

Practiceboundaries
Theitem'structuredandopenchannelsofcommunicationexistbetweenhealthcareprofessionalsand
patients,carersandorganisationalmanagement'wasremovedfromthisconstructandthecorrelation
increasedto0.50(P=0.000).

Evaluation
Theitem'performancemeasures(staffturnover,lengthofstay,etc)areinplace'wasremovedfromthe
correlationanalysisandthisactuallyreducedthecorrelationscoreto0.36,butstillatastatisticallysignificant
level.

28

Table12:CorrelationofamendedconstructscoresatT1andT2(*P=0.05,**P>0.001)
Construct

Pearson'sproduct

Spearmansrho

Collaborativepractice

0.46**

0.43**

Evidenceinformedpractice

0.73**

0.82**

Respectfortheperson

0.66**

0.59**

Practiceboundaries

0.51**

0.50**

Evaluation

0.36*

0.36*

Thepairedconstructscoresforeachofthefiveconstructswereenteredonascatterplot,producing115pairs
ofresponses(23times5).Abestfitlinewasfittedfromtheorigin(coordinates0,0).Thelinewasdetermined
bycalculationoftheleastsummedsquaresofresidualsfromthefittedline.ThisproducedaSpearmansrho
correlationof0.56,P=0.000(0.59Pearsonsproduct,P=0.000)betweenbothtimepointsatasignificance
levelof0.001.Thelineofbestfitindicatesastrongrelationshipbetweenthetwotimepoints.Thescatterplot
isshowninFigure1.
IngeneraltheCAIcanbeconsideredareliableinstrument.Minormodificationsaresuggestedfortheremoval
ofitemswithlowpercentageagreementscores(below55%),andthechangesthesewouldproduce
highlighted.However,theremustbeabalancebetweenthecontentvalidityandthestatisticalreliabilityofthe
instrument,whichisapointforfurtherdiscussion.Furthertestingoftheinstrumentmayhelptorefinethese
findings.

scatter2 = 0.99 * scatter1

A

3.0

Data Time 2

2.5

2.0

A A
A
A
A
A
A
AA
A A
A A
A
A
AA
A
AA A
A
A A
A
A A A AA
AA
A A
A
A
A
A A A
A
A
A
A
A
A
A
A A
A
A
A
A A A

A
A

1.5

A
A
A

1.0

A A
A

A
A
A

1.5

AA

A
A
A

2.0

2.5

3.0

Data time 1

Figure1.Scatterplotofresponsesfromfirsttestattimeone(T1)andretestattimetwo(T2)withalineof
bestfit.

29


Usabilitytestingbytelephoneinterview
Nursemanagersateachsite(20intotal)whohadtakenpartinthetestretestwereinvitedtoparticipateina
telephoneinterviewtodiscusstheusabilityoftheCAIandassociatedguide.Aschedulewassenttooutpriorto
theinterview,andeachinterview(seeAppendix6)lastedapproximately20minutes.Theinterviewerwrote
responsesdownasthepersonwasspeaking,andreadthembackattheendtoensuretheyhadbeennoted
correctly.

Results
MostintervieweesdidnothaveaproblemunderstandingthestatementsintheCAIandstatedthatitwasuser
friendly.Twohadbeenannoyedbysomerepetition:something(thestatements)askedinadifferentway
althoughonepersonthoughtthismadethemreadeachstatementcarefully.Onewasnotclearabouta
statementthatrelatedtohierarchicalmanagementstructure.ThelanguageoftheCAIwasconsideredeasyto
understandanditwashelpfultobegivenaguidetoabbreviationsattheoutset.Animportantpointwasmade
aboutthedifferenceinanswersthatmightbeprovidedbymanagersandstaff,inasmuchasmanagersmay
believetheyaredoingagoodjobwhilepractitionersoftenfeeldifferently.Anotherindividualstatedthat'staff
nursesmaynotbeinapositiontoanswersomeofthequestions'andsuggestedthatthetoolwasmoresuited
tonursemanagers
ThetimetakentocompletetheCAIwas1020minutesandnooneexpresseddifficultywiththis.Onesaidthat
ifsheuseditregularlyshewouldbeabletocompleteitevenmorequickly.
Allintervieweesfoundtheaccompanyingguidehelpfulandinformative,enablingthemtounderstandhowto
usetheCAIandguidingthemthroughtheprocess.Theyallfeltthatnothingwasmissingfromtheguide.
However,threeofthemhadconcernsaboutthelengthoftheguideandqueriedwhethermostpeoplewould
takethetimetoreadit.Onepersonadmittedtheyhadjustscannedoverit,whileanothersaiditwasvery
detailed,andanothersuggestedthatreasonsforduplicationofquestionsshouldbeexplainedwithinthe
guide.Onerespondentthoughtashorterversionwouldbebetterandsuggesteditneededtidyingup.
Intervieweeswithanacademicbackgroundsaidtheywouldnotneedsuchacomprehensiveguide(tootime
consuming).
AllintervieweesrecognisedthatthepurposeoftheCAIwastoassesscontinencewithamultidisciplinaryfocus.
Fourofthemrealisedthatthefocuswentbeyondcontinenceassessment.Onewardmanagersaid:'itistohelp
nursesunderstandallthefactorsaffectinggoodcontinencecare,thewiderpictureofthingswedontseeor
normallythinkaboutwhenlookingatcontinence'.Onepersonsaidthattheysawitasan'evaluationof
individuals'attitudestotheirworkenvironment'.However,anotherwardmanagerstatedthatshedidnot
understandthepurpose:'Alotofthequestionswerenotrelevanttocontinence.Notsurewhatitwas
assessing'.Interestinglynooneactuallyreferredtocontextspecifically.
IntervieweeswereaskediftheythoughttheCAIwasrelevanttoclinicalpracticeand,ifitwereavailable,would
theychoosetouseit.Significantly,allofthemfeltitwasrelevanttotheirclinicalpracticeandthirteenofthem
saidtheywoulduseit.Theysaidthatithighlightedissuesabouttheirpracticesuchas:'Itmademethinkabout
thewiderpicturetheunseenpartsofcaringthatwedo.Thoughtabouthowwedonthaveamultidisciplinary
approachtocontinencecare,itsnotahighpriority'.AllrespondentsagreedthattheCAIwasrelevanttotheir
clinicalarea.Onesuggestedthatherunitwasfortunatebecauseaccreditationwasunderway,soconditions
weregoodatthetime,buttheCAIhelpedher'tothinkoffutureprojectsthatcanimprovepatientcentred
care'.Oneparticularareaofpracticewashighlightedbyonepersonthatis'encouragingpatientstobeinvolved
inprovidingfeedbackontheircare'.Anothersaiditmadeher'stopandthink,andthatanythingthathelpsstaff
toreflectonpracticeisgood'.Onecommentedthat'theCAIcanalsoaffirmpositiveaspectsofcare'.Two
peoplepickedoutparticularareasinwhichtheCAIhadhighlightedneedforchangesperformancereview
andevidencebasedpractice.ThewardmanagersalsosuggestedthattheCAIcouldbeusedwithothertopics,
suchaswoundcareanddocumentation.

Conclusion
TheintervieweesdidnothavetheCAItorefertoduringtheseinterviewsandmanycouldnotrememberit.
TheyrequestedtoseetheCAIagainandrescheduledtheinterview.Moreinformationmayhavebeen

30

generatediftheinterviewshadbeencarriedoutimmediatelyaftercompletingtheCAI.Onthewhole,
responsesabouttheusabilityoftherevisedCAIwerepositive.Somereductioninthelengthoftheuserguide
wouldreducetheburdenofcompletingthetool.Someoftheintervieweesdidnotfullyunderstandthelinkto
evidencebasedpracticeandtothewiderculturalaspectsoftheorganisation.Clearly,theyfoundpartsofthe
CAIchallengingastheyassociatedcontinenceatwardlevelandenvisageddifferencesbetweenmanagersand
wardbasedstaff.ThiscouldsuggestthattheCAIisbestimplementedthroughacoordinatororapersonwhois
abletoengagethepersoncompletingtheCAItoreflectonitsmeaningtotheirpractice.Itwasencouraging
thatmostintervieweesstatedtheywouldusetheCAIandfoundthatithelpedthemtoreflectontheir
practice.

Summaryofdatacollectionandanalysis
TheanalysisofdatafromPhase1providedalistofstatementsthatwasreviewedbytheprojectteamand
formedtheinitialCAI.Thistoolwasthenrefinedbyprepilotandpilotingtestingforclarity,
comprehensiveness,usabilityandspecificitywithcontinencenursespecialistsandpracticedevelopment
nurses.Therevisedtoolwasthentriedoutinalargesampletotestthefactorstructureforvalidityin936
nurseswhoworkedinrehabilitationofolderpeople.Factoranalysisofthisdataresultedinfurtherrevisionof
thetooltoa44itemstructure.MeasuresofhomogeneitywerecalculatedandCronbach'salphascoreforthe
completetoolwas0.93.AtestretestoftheCAIwasthenconductedtocheckitsreliabilityovertime,analysed
usingcrosstabulationsandKendall'staubscores,andresultingintheformationoffiveconstructs.Afew
minormodificationsincreasedthecorrelationscoretoastatisticallysignificantlevel.Finallytheusabilitywas
assessedbyinterviewing20nursemanagerswhohadtakenpartinthetestretest.GenerallytheCAIis
consideredareliableresearchinstrument(Cronbach'salphascore0.93)thatisuserfriendlyandacceptableto
clinicalstaff.

FinalrevisionsoftheCAI
SevenstatementsidentifiedasstatisticallyweakandconsideredinsignificanttotheaimsoftheCAIwere
removed,leaving38items.Theywere:

HCPsandpatientshaveaccesstoappropriatediagnosticequipment.

HCPsareempoweredtoinfluenceexternalfactorsaffectingcare.

Organisationalstructuresandprocessesarecleartopatients,HCPsandhealthcaresupportworkers.

FeedbackisatwowayprocessbetweenpatientsandHCPs.

Regardisgiventothepatient'spsychologicalandspiritualwellbeing.

Structuredandopenchannelsofcommunicationexistbetweenhealthcareprofessionalsandpatients,
carersandorganisationalmanagement.

Performancemeasures(staffturnover,lengthofstay,etc)areinplace.

Theexplanatoryguidewasamendedfollowingfeedbackfrominterviewees.TheCAIandtheguidecanbe
foundinAppendix7.

31

SECTION7
Finaldiscussionandrecommendations
Discussion
ThePARIHSframeworkwasdevelopedthroughtheworkoftheRoyalCollegeofNursing(RCN)institutes
analysisofvariousretrospectiveprojectstheyhadundertaken.Theframeworkwasanattempttounderstand
thecomplexfactorsinvolvedinimplementingevidencebasedpractice(evidence,contextandfacilitation).This
studyfocusedonassessingthecontextwithinwhichcontinencecareisprovidedanddevelopingatoolto
assesspracticecontext.Thecomplexnatureofcontext(comparabletotryingtocatchacloudaccordingtothe
CHSRF(2005)usuallyrendersitinvisibletopractitioners,sotheyareleftwonderingwhytheyareunableto
implementevidencebasedpractice.ThroughdevelopingtheCAIwehaveprovidedpractitionerswithameans
toassessandunderstandthecontextinwhichtheyworkandtheimpactthishasonimplementingevidence
basedpractice.
Weknowfromtheliteraturethatasubstantialbodyofknowledgeregardingevidencebasedcontinencecare
exists,butpractitionerscontinuetoprovidereactivecontinencemanagementratherthanapplyavailable
evidenceofbestpractice.ThiswassupportedbyfindingsfromPhase1ofthestudywhichfoundthatthe
context(leadership,cultureandevaluation)inbothstudysiteswasweakandnotconducivetopersoncentred
careandmanagement.
Ourdatashowedthatpractitionershadsomeinsightsintothecontextualfactorsthathinderorenhance
evidencebasedpractice.However,aprevailingcultureofunclearbeliefsandvalues,andatendencyfor
autocraticleadership,meanstheyfeeldisempoweredtochangetheirpractice.ThisisillustratedinTable{4}
wherebymoreautocratic(ratherthantransformational)formsofleadershipcreateteamsthatareunableto
optimiseskills,abilitiesandknowledge.Staffwereawareoftheseleadershipeffectswithrespecttocontinence
practice.Onepersonexpressedtheopinion:'Newideassortofcomeandgoandyoursortofyouknow
cantgetonwithnewthings.Wehavemeetingsandeveryonesays"Yes"butnothinghappens.Itsnotright
butIjustkeepmyheaddownnowdontwanttokeepaskingaboutthings'.
Approachestocareofcontinenceisreactive,involvinglimitedassessmentsandheavyrelianceonapadand
pantsapproach.SimilarobservationsweremadebyBlandetal.(2003)andGray(2003).Moreover,continence
problemsareoftenacceptedaspartoftheagingprocess,whichmeansthatnursesoftenfailtonoticethe
significanceofcontinenceinrehabilitationofolderpeople.
Participantsinthisstudywereawareofthedeficienciesintheirownsites'careandmanagementof
continence,agreeingthatcontinencewasnotseenasapriorityandthattheenvironmentinwhichthey
workedwasnotalwaysconducivetopersoncentredcare.Theydidacknowledgethechallengesaheadof
them.Oneparticipantstated:'Wecoulddopatienttrainingasagrouptohelpthepatientsunderstand
continence.Dontthinkwedoenoughnowjustgetthepadsanddontaskwhattheyknow'.Furthermore,
opportunitiesforreflectionarelimited,andoftenroutinepracticesgounchallenged.Despitetheprovisionof
classroomteaching,itisclearthatmerelyprovidinginformationdoesnotchangepractice(RycroftMaloneet
al.2002).Withoutaculturethatisreceptivetonewideasandwaysofworking,approachestocareremain
taskbased.Olderpeoplewithincontinencewillsufferfromlimitedchoiceandlessthanadequateassuranceof
privacyanddignity.WeuseddatafromPhase1ofthestudytodevelopatoolthatenablesnursesandother
healthcareprofessionalstoassesscontextualfactorsintheirownareaofpractice,factorsthatenhanceor
hinderpersoncentredcare,inthiscaseofcontinenceinolderpeople.
InPhase2thedevelopmentoftheCAIwentthroughfivestagesoftestingforreliability,validityandusability
withpractitionersfromtheUKandRepublicofIreland.TheCAIprovedtobeavalidandreliabletool.What
addstotherigouroftheCAIisthescaleofthestudy,encompassingallofIreland,sothatawiderangeofdata
weregeneratedforanalysis.DatafromsitesinboththeRepublicofIrelandandNorthernIrelandhighlighted
thesameissues,sowecanassumethatourfindingshavewiderapplicabilityandaremoregeneralisablethan
wouldhavebeenthecaseifthestudyhadbeenconfinedtoonearea.
PractitionersstatedthattheywouldusetheCAIifitwasavailableandthatusingtheCAIenabledthemto
reflectontheirpractice,asevidencedbythesewordsfromawardmanager:'Mademethinkaboutthewider
picture,theunseenpartsofcaringthatwedo.Thoughtabouthowwedonthaveamultidisciplinaryapproach

32

tocontinencecare'.AnotherwardmanagerstatedthattheCAIhelpedher'tothinkoffutureprojectsthatcan
improvepatientcentredcare'.
TheCAIcanhelppractitionersreflectontheircurrentpractice,butthereisnotyetanyprocessforpractitioners
toformallyanalysetheoutcomeoftheCAI.TheadditionofaninterpretationfortheCAIwouldfurtherincrease
itsvaluetodevelopingpractice.WefeelthattheCAIhasthepotentialtobringaboutpracticechanges,but
untilithasbeenwidelyappliedtopracticewewillnotknowhoweffectiveitisatfacilitatingchange.
FeedbackfrompractitionerssuggeststhattheCAImayhavevalueindifferentsettingsandindifferentareas
suchaswoundcareanddocumentation.Itcouldbeusedasagenerictoolwithindifferentareas,butfurther
researchwouldbeneededtoensurevalidity,reliabilityandusabilityinothersettingsoraspectsofpractice.
ThenextstepisimplementtheCAIindesignatedclinicalareasandevaluateitsimpactondevelopingpractice,
withresearchfocusedonthereliabilityandvalidityinothersettings,tofurtherdetermineitsvalueinclinical
practice.Finally,theCAIcouldbeusedtoexploremoredeeplythemeaningofcontextanditsimpacton
implementingevidenceintopractice.

Conclusions
ThiswasthefirststudytotestthetheoreticalelementofcontextfromthePARIHSframeworkinpractice.The
aimwasnottotesttheoriginalPARIHSframeworkbuttodevelopatooltoenablecontexttobemeasured.The
elements(collaborativepractice,evidenceinformedpractice,respectforpersons,practiceboundaries,
evaluation)andstatementsthatarosethroughthedevelopmentoftheCAIareamoredetailedanalysisofthe
contextframeworkandcanbemappedontotheoriginalcontextframework.ThisisillustratedinTable13.

Table13:MappingofCAIelementstothecontextframework
Contextframework

CAIelement

Culture

Collaborativepractice;Practiceboundaries

Leadership

Respectforpersons

Evaluation

Evidenceinformedpractice

Throughoutthestudy,modificationswereincorporatedintothecontextframework.Theuseofcontextasan
elementwasconfusingbecausetheaimofthecontextframeworkwastoassesscontext,soitwasremoved
anditscharacteristicsweretransferredtotheotherthreeelements.
Wefoundseveralareasofoverlap,andthereforethreecharacteristicswereamalgamatedasdiscussedabove.
Table14illustratestherevisedcontextframework.
ThecontextframeworkinPhase1wasusedtoanalysethedata.Thisillustratedthecomplexfactorsleadingto
weakandstrongcontextandtheirimpactonthequalityofcontinencecareinthetwostudysites.Itconfirmed
thatthecontextwithinwhichcareisprovidedismultifaceted.
Thescaleofthestudyandthecollaborativeapproachenabledsystematicandrigoroustestingofthevalidity
andreliabilityoftheCAI,allowingassessmentofthecontextfactorsthatenhanceorhinderpersoncentred
careofolderpeoplewithincontinenceundergoingrehabilitation.PractitionersdescribedtheCAIasuser
friendlyandrelevanttotheirpractice.

33

Table14:Revisedcontextframeworkfollowingorganisationofdataforanalysis
Elements
Culture

WeakcharacteristicsStrongcharacteristics
Lackofclarityaroundboundaries
Unclearvaluesandbeliefs
Lowregardforindividuals
Taskdrivenorganisation
Lackofconsistency
Notreceptivetochange

Boundariesclearlydefined(physical,social,culturaland
structural)
Abletodefineculture(s)intermsofprevailing
valuesandbeliefs
Valuesindividualstaffandclients
Promoteslearningorganisation
Consistencyofindividuals'roleorexperiencetovalue
relationshipwithothers,teamworking,powerand
authority,rewards/recognition,receptivenesstochange

Leadership Traditional,commandandcontrolleadership
Lackofroleclarity
Lackofteamwork
Didacticapproachestoteaching/learning/
managing
Autocraticdecisionmakingprocesses
Lackofappropriatenessandtransparency
Lackofpowerandauthority

Transformationalleadership
Roleclarity
Effectiveteamwork
Enabling/empoweringapproachtoteaching/learning/
managing
Appropriateandtransparentdecisionmakingprocesses
Powerandauthorityunderstood

Evaluation

Feedbackonindividual,teamandsystems
Useofmultiplesourcesofinformationonperformance
Useofmultiplemethods(clinical,performanceand
experience)
Effectiveorganisationalstructure

Absenceofanyformfeedbackand
information
Narrowuseofperformanceinformation
sources
Evaluationsrelyonsingleratherthan
multiplemethods
Poororganisationalstructure

34

Recommendationsforfutureresearch
ImplementtheCAIintopractice
TheCAIshouldbeimplementedindesignatedclinicalareastoevaluateitsimpactondevelopingpractice.This
couldbeabeforeandafterstudythatusespracticedevelopmentmethodologytoassessthecontextusingthe
CAI,developpracticefromthefindings,thenreevaluateit.Thiswouldalsoprovideanopportunitytotestthe
analysisprocessfortheCAI.

TestthevalidityandreliabilityoftheCAIgenerically
TheCAIwasdevelopedforuseinolderpeopleundergoingrehabilitation,withaparticularfocusoncontinence
issues.However,theCAIwouldhavevalueinotherspecialties.Researchcouldbeundertakentotestthe
reliabilityandvalidityoftheCAIinotherclinicalsettings.

Refinethecontextframework
Theframeworkcouldexplorefurtherthemeaningofcontextanditsimpactonimplementingevidenceinto
practice.ThedevelopmentoftheCAIprovedthatsomecharacteristicsarelesstheoreticallyrobust,suggesting
thatthecontextframeworkcouldberevised.Researchtofurthertesttherobustnessofthecontextframework
isthereforerecommended.

DevelopandtestofaninterpretationprocessfortheCAI
SuchaprocesswillenablepractitionerstointerprettheirfindingsfromtheCAI.Itshouldincludeasectionthat
allowsthemtoreflectontheresultsandtheirmeaningtopractice.Aprocesslikethiswouldneedtobe
developedwithpractitionerstoensurereliabilityandvalidity.

35

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38

Appendix1
Datacollectioninstruments
Semistructuredobservationofpracticeframework
Observationofpracticerelatingtothefactorsthatenhanceorhindercareandmanagementofcontinencein
olderpeople,usingManley'sculturalindicators(Manley2000a)andEssenceofCare(DH2001b).
Unit:

______________________________________________________________

Ward/department:

______________________________________________________________

Timeofobservation:

______________________________________________________________

Namesofobservers:

______________________________________________________________

Time

Patientcareactivity

Thoughts/comments/feelings

39

Contextualindictorsthathinderandenhancecontinencecareand
management
Thecomponentsofa
transformationalculture

EssenceofCarebestpracticecontinence
benchmarksasindicatedbypatients

Sourceofinformation
(observation,patientsnotes,
talkingtostaff)

STAFFINDICATORS

Staffcontinuallydeveloptheir
practiceandselfknowledge

Staffuseevidenceofbestpracticeof
continencecareandpromotion

Staffhaveaclearsenseofpurpose
Staffcommunicatefreely,question,
challengeandsupporteachother

Assessmentofpatients'continenceis
undertakeninresponsetotrigger
questions

Staffuseformalandinformalsystems
thatfostercriticalthinking

Careiscontinuouslyplanned,implemented
andevaluatedbasedontheassessment

Staffareenabledtodevelop
knowledgeandskills

Staffseekchallengeandsupportabout
theirknowledgeandskillsoncontinence
care

Teamscontinuallydeveloptheirown
practiceandtheirselfknowledge

Staffundertakespecificcontinence
educationandupdates

PATIENTINDICATORS

Patientcentredcareisdesigned
aroundtheneeds,concernsand
experiencesofpatients/carers

Continencecareisdeliveredinan
environmentconducivetothepatients'
individualneedsandwishes

Activityisfocuseddirectlyonpractice
andhowknowledgeandskillsare
usedinpractice

Assessmentofpatientsisongoingand
basedonpatientinterviews

Evidenceusedtoinformdecision
makingisdrawnfrompolicy(from
localtoglobal)
Differenttypesofknowledgeare
used:propositional(researchand
theory)knowledge,craftknowledge,
localtheory,andpatients'own
knowing

Staffapplyknowledgeandskillsofperson
centredpractice
Thereisinformationoncontinencecare
forpatientsandcarers,adaptedtomeet
individualpatientneeds
Patientsarereferredtospecialistservices
whocanmeettheircontinenceneeds,and
theseservicesareactivitypromoted
Staffcanverbaliseandthrough
documentationtherationalefortheir
actions

WORKPLACECONTEXT

Qualityiseveryonesconcern

Continencecareknowledgeandskillsis
developedandevidentatalllevels

Espousedvaluesandbeliefsare
realisedinaction
Thereisafocusondevelopingthe
leadershippotentialofallstaff

Serviceusersarealwaysinvolvedin
planningandevaluatingcontinence
services

Allstakeholdersarevalued(staff,
patients/carers,etc.)

Resourcesforcontinencecaremeetthe
patients'specificneeds

Allopportunitiesaretakentopromote
continenceandahealthybladderand
bowel

40

Observationofpractice,continenceandolderpeople
Thistoolhasbeendevelopedtoaidintheobservationofnursingpracticewithaparticularfocusoncontinence
andolderpeople.Thetoolincorporatesthecomponentsofatransformationalcultureandrelatedcultural
indicatorsdevelopedbyKimManley,andtheEssenceofCarebenchmarksofgoodcontinencecareasidentified
bypatients.Theaimistogaininformationthroughobservationofnursingpracticeonthefactorsthathinder
andenhancethemanagementofcontinenceforpatientswithinElliotDynes.Thekeyculturalindicatorsand
theEssenceofCarebenchmarkingwillactastriggersfortheobservationandaidtheobservationtofocuson
bestpracticeratherthantheobserver'sownperceptionofthecarethatshouldbeprovidedtopatients.
Theobservationisundertakenbytwopeoplefor2hourperiods.Attheendoftheobservationtheobservers
comparenotestakenduringtheobservationanddiscussanysimilaritiesanddifferencesinhowthenursing
practicemeetstheculturalindicatorsandEssenceofCarebenchmarks,andanyfactorstheyobservedthat
enhancedorhinderedthesefindings.

Guidetoundertakingobservationofpractice

Verbalexplanationofthepurposeoftheobservationisgiventopatientsalongwithwritteninformationat
least24hoursbeforetheobservationtakesplace.

Verbalconsentisgainedfromstaffthatwillbeondutyduringtheobservation.Ifanymemberoftheteam
declinestotakepartthennoneofthepatientinterventionsofactionsarerecorded.

Observersreviewthenursingnotesofthepatientswhosecaretheywillbeobserving,priortocommencing
theobservation,notinghowthepatients'continenceisassessedandplanned.

Observersshouldaimtoobservethecareofthesamegroupofpatients.

Donotdiscussyourobservationsuntiltheendoftheobservationperiod.

Itisbestnottowearuniformsothepatientswillnotaskforyourassistance.

Itmaybenecessarytoassistapatientbutonlydothisifpatientcareisbeingcompromised.Ifyoudo
interveneonbehalfofapatient,notethisdown.

Useallyoursenseswhenobserving(e.g.includingwhatyoucanhearorsmell).

Donotinteractwithotherhealthcareprofessionals,andiftheybegintotalktoyoupolitelyexplainthat
theymustjustcarryonasifyouwereinvisible.

Takenotesasyouareobservingusingthechartincludedbutdonotworryaboutfittingallinformation
intothechart.Youcanmakenotesthenrefertothechartagainattheend.

Nopatientorstaffnamesaretobeused.

Goodluck!!
JayneWright(October2004)

41

Staffcontinenceknowledgequestionnaire

MULTIPLECHOICEQUESTIONS

ANSWERS

Q1

Areyoua:

1.CNM
2.Staffnurse
3.Medicalconsultant
4.Medicalregistrar
5.Medicalhouseofficer
6.Physiotherapist
7.Occupationaltherapist
8.Other(pleasespecify)

Howwouldyoudescribeyourknowledgeof:

Continencepromotion?
1.Verygood
2.Good
3.Average
4.Poor

Q2

Themanagementofcontinence?
5.Verygood
6.Good
7.Average
8.Poor
Anatomyandphysiologyrelatedtoincontinence?
9.Verygood
10.Good
11.Average
12.Poor
Thedifferenttypesofincontinence?
13.Verygood
14.Good
15.Average
16.Poor
Q3

Whodoyouthinkshoulddothefirstassessmentfor
clientswithincontinence?(morethanoneanswermay
begiven)

Athome:
1.Continenceadvisor
2.PHN
3.GP
Atschool:
4.Schoolnurse
5.PHN
Inhospital:
6.Continenceadvisor
7.CNM
8.Staffnurse
9.Medicalconsultant
10.Registrar/seniorhouseofficer
11.Other(pleasespecify)

Q4

Incontinenceofurineaffects:

1.About2%ofwomenover65yearsold
2.About5%ofwomenover65yearsold
3.About10%ofwomenover65yearsold

Q5

Thebladderofanewbornbabyiscontrolledby:

4.Thecerebralcortex
5.Localsynapsesinthebladderwall
6.Asacralreflexarc

Q6

Thepelvicfloor:

7.Supportstheurethralsphincter
8.Isanothernameforthepubicbone
9.Isthebottompartofthebladder

Q7

Anaverageadultbladderatcapacityholds:

10.200mL
11.350mL

42

12.500mL
Q8

Anaverageadultpassesurine:

13.23timesperday
14.47timesperday
15.812timesperday

Q9

A'residualurine'is:

16.Thetotalcapacityofthebladder
17.Theamountleftinbladderaftervoiding
18.Postmicturitiondribble

Q10

Normalresidualurineis:

19.0mL
20.0100mL
21.100200mL

Q11

Ahypotonicbladderhas:

22.Excessivecontractility
23.Insufficientcontractility
24.Areducedcapacity

Q12

Encopresisis:

25.Playingwithbodilywastes
26.Dayandnightincontinenceofurine
237.Incontinenceoffaeces

Q13

Retentionwithoverflowisnotasymptomof:

28.Detrusorinstability
29.Outflowobstruction
30.Hypotonicbladder

Q14

Ahighresidualurinecanbeexpectedwith:

31.Stressincontinence
32.Urgeincontinence
33.Hypotonicbladder

Q15

Anticholinergicdrugsmaybeusedtotreat:

34.Stressincontinence
35.Urgeincontinence
36.Retentionwithoverflow

Q16

Parentsattitudeswhendealingwithchildrens
incontinenceshouldbe:

37.Calm
38.Scolding/disapproving
39.Punishing

Q17

Stressincontinencecanusuallybeimprovedby:

40.Surgery
41.Pelvicfloorexercises
42.Medication

Q18

Whatmighthelpreduceurgencyandfrequency?

43.Reducingcaffeineintake
44.Restrictingfluids
45.Diuretics

Q19

Whenisintermittentcatheterisationuseful:

1.Whenalargeresidualisfound
2.Withurgeincontinence
3.Inyoungersufferers

Q20

Whatsizecatheterwouldyourecommendinanaverage
female:

4.12Chwith30mLballoon
5.12Chwith5mLballoon
6.10Chwith30mLballoon

Q21

Whichvitaminsupplementwouldyousuggesttoreduce
encrustationofalongtermcatheter:

7.VitaminA
8.VitaminB
9.VitaminC

43

Appendix2
Focusgrouptopics
Theaimofthisdiscussionistoconsiderthecharacteristicsthatenableandhinderproactivecontinence
managementwithinthisunit

1.Toenableproactivecontinencemanagementthefollowingarenecessary:
specificcontinenceassessment
clearrationaleprovidedfortreatmentdecisions
consistencyandcontinuityinapproachestocontinencemanagement
evaluationofcare.
Howdoyouthinkthisrehabilitationunitperformsin(eachof)thesefourareas?

2.Proactivecontinencemanagementispatientcentred(e.g.providingpatientinformation,timefordiscussion,
involvementindecisionsabouttheircare,choiceoftreatment,promotionofdignity,etc.).
Howdoyouinvolvepatientsindecisionsabouttheircontinencecare?
Howisdignityandrespectpromotedandachieved?

3.Goodleadershipandeffectiveteamworkisnecessarytoenableproactivecontinencemanagement.
Howmuchpriorityisgiventoensuringthatbestpracticeisadheredtobyteammembers?

4.Inyouropinion,isthemanagementofcontinenceamultidisciplinaryresponsibilityortheresponsibilityof
individualswithintheteam?Pleasegiveexamples.

Thankyouforparticipating
JayneWrightandAliceCoffey

44

Appendix3
Extractsfromanalysisusingcontextframework
Clarityaroundboundaries(physicalsocial,culturalandstructural)vslackofclarityaround
boundaries
Thedatasuggestedsomeconfusionaroundboundaries.Forexample,therewasamergingofprofessionaland
personalboundariesbetweenstaffwhichappearedtopreventpracticefrombeingchallenged.Thisissummed
upbyoneofthefocusgroupparticipants:'Youmustacceptthatsomeofushaveworkedhereforyearsandare
friendsandthatmakesagoodteam.Youknowpeoples'waysandhowtheyareandifyoudontknowthat
nursewhomightthinksheis,youknow,notbeingright,butitsherway'.
Thetherapists,nursesanddoctorswereawarethatcontinencewasseenasthenursesresponsibilityandthis
seemedtobeanareaoftensionbetweenthenursesandtherapists.Onetherapiststatedatthefocusgroup:
'Weareslightlyguiltyofattheendofthesessionandtheywouldsaytheyneedtogotothetoilet,andsay
"Right,youcangowhenyougobackuptotheward".Thatwouldbesomethingweareguiltyofbutourtoiletis
usedconstantlydownthere'.
Atanotherfocusgroupanurseemphasisesherroleasliaison:'Well,weliaisewiththemedicalteamallthe
timewithregardtoanymedicationtheyneed,withthe[occupationaltherapist]forequipmentgoinghome,and
thephysiowellformobilisingtothetoilet.Itsatopicthatisoutthereallthetimeasamultidisciplinary
problem'.Andanoccupationaltherapistcommented:'everywhereIworked[continencemanagement]tended
tobethenurses'role'.
Somewerehappytoseeboundariesmoreblurred,likethisdoctor:'Ifirmlybelievethatitisamultidisciplinary
responsibility'.Andaphysiotherapistaddedthatthepatients:'thinkweareallnursesanyway'.
Patientswereaskedaboutfactorscontributingtotheircontinenceproblem.Mostcitedphysicalfactors(64%)
asopposedtoenvironmentalfactors(19%).Thiswascompoundedbyrestrictionsimposedbytheculture,
evidencedbychairsthatpatientscouldnotgetoutofeasily,andplacementofsomepatientsatsomedistance
fromthetoiletfacilities.

Beingreceptivetochangevsnotbeingreceptivetochange
Theculturewasonewherenewideasandwaysofworkingwerenotsustainedinpractice.Thisleftthestaff
feelingreluctanttomakesuggestionsonhowpracticecouldbechanged.Thisdissonancebetweenhowthey
wantedtopracticeandtheirexistingpracticecausedsomediscomfort,compoundedbythefactthattherewas
nocontinenceeducationwithintheunitonaregularbasis(RCPaudit).
Thisisillustratedbycommentsatthefocusgroups:'Newideassortofcomeandgoandyoursortof,youknow,
cantgetonwithnewthings.Wehavemeetingsandeveryonesays"yes"butnothinghappens.Itsnotright,
butIjustkeepmyheaddownnow.Dontwanttokeepaskingaboutthings.'
Inanotherfocusgroupanexplanationwasputforwardforlittlechangeinexistingpractice:'Perhapsinthe
absenceofacontinenceadvisoralleducationandinductionbecomesbittyandthatisdefinitelyabarrierto
evidencebasedpractice.'
Enthusiasmforchangewas,however,foundinoneofthefocusgroups:'Benchmarkingisgoingonatthe
momentwiththeEssenceofCarethelatestbuzzworditwillgiveusatemplatetoworkwith.Itwouldbe
helpfulifwehadmoreinputfromthequalityofficeencouragingmoreauditingofpractice.'
TheNursingWorkIndex(NWI)scoreswereonamoderatelypositivesideofthescale:'nurseautonomy'scored
2.87,'controloverpractice'scored2.39,'nursedoctorrelationship'scored2.91and'organisationalsupport'
scored2.67.Theresultsoverallindicatedalowtomoderateperceptionofcontroloverpractice,autonomyin
practice,andgoodnursedoctorrelationships.

45

Characteristicsofculture
Abletodefineculturesintermsofprevailingvaluesandbeliefsvsunclearvaluesandbeliefs
Manyexamplesillustratedthathealthcareprofessionalsdidnothaveclearbeliefsandvaluesaboutworking
witholderpeopleandtheprovisionofproactivecontinencecare.However,theyappearedtobeawareofthis
asstatedduringonefocusgroupmeeting:'Theissuehasbeenraised.Youknow,maybemakingusconsider
morewhatthepatientisgoingthroughandmaybebeingmoreempathisingoftheirsituation.Becauseyoucan,
afterworkingforyears,getusedtoit,thatyouactuallynearlythinkitisnormalratherthanrealisingit'snot
howitshouldbeyouknow,itisawfulforsomeonetohavethatproblemsonotbeingblas'.
Thecommentssuggestthatsomestaffacceptedcontinenceproblemsasaninevitablepartofagingandhad
lostsightoftheeffectithadontheolderpersonslife.ThisissupportbytheRCPauditwhereinalmosthalfthe
casestherewerenodocumenteddiagnosesofincontinence.Justafewcaseswerereferredtoanursingor
medicalspecialist,andcontinencechartswereusedforonlyasmallnumber.Documentaryevidenceoffollow
upwasnotpresentinthemajority.However,inanotherfocusgroupanursestresses:'Wedontjustaccept
that[thepatients]areincontinentandjustputapadonthatsnotacceptablewecreateawarenessinthe
staff'.

Valuestoindividualstaffandclientsvslowregardfortheindividual
Careoftenappearedtobebasedontasksandroutines,leavinglittlespaceforpatientchoiceordecision
making,andresultingininflexibilityintheestablishedroutinesoftheday,ashighlightedintheseobserver's
fieldnotes:'Lightsonfullat07.40andwardnoise.Lotsofpatientsalreadyupbutmostasleepinthechair.No
apparentperceptionbythestaffthattheyshouldbequietaspatientsresting.Talkingloudly'.Anotherobserver
noted:'Careassistantcomesintoward,openswindowandturnsradioonloudlyshedoesntaskpatientsif
theywouldlikethewindowopenorcloseditcanbeverycoldwhenstationeryforalongtimeandeveryone
doesntlikepopmusic.'
Butthereweretimeswhenthecareisverypersoncentred.Again,fromtheobservationfieldnotes:'Apatient
asksoneofthenursesaboutachiropodyservicesheisinformedpromptlyabouttheavailabilityoftheservice
andofferedareferralifrequired.'Andonanotheroccasion:'Adoctoristalkingonthecorridortoapatient
socialchataboutthepatientshome.Thepatientisenjoyingthechat.Doctorisveryattentiveandseemsto
haveagreatrapportwiththepatient.Goodcommunicationskillstouch,paraphrasing.'.Anotherobserver
reported:'Patientsaskforreplenishmentofdrinkingwater.Thisisdoneimmediately.Ihavenotwitnessedany
patientwaitingforanyserviceheretoday.'
Itisknownthatlimitedindividualisedcareaffectspatientdignity.ForexampletheRCPauditinonesite
showedthat85.6%hadbodywornpadswithnostatedrationaleforthiscontainmentapproach.Furthermore,
53.7%ofthepatientswearingpadswerestilloccasionallywetand38.85%wereusuallywet.
Suchissuesareencapsulatedinthefollowingobservationsofpractice:'Thenursingassistantaskedthepatient
ifhehadfinishedonthetoilet.Thenanothernursingassistantcamealongandstoodwithhimsaying"Haveyou
finished?".Theseinteractionstookplacewhilethetoiletdoorwasajarandthepatientwassittingonthetoilet.'
Andonanotheroccasion,anursespoketooneofthedependentpatients,saying:'Wewillbeturningyouevery
twohoursbecauseyourbottomissore.'Theobservernoted:'Isthereaneedtogointodetailwithinearshotof
others?'.
Inoneofthefocusgroupdiscussions,anursesaid'Dignityandrespect,thatsallpartofitfortheindividualand
basicallytreating[patients]asyouwishyouorotherstobetreated.Thatgoeswithoutsaying'.However,the
continenceproblemsfacedbytheolderpeopleinthisstudywerenotdiscussedwiththem,accordingto62%of
thematsite1and97%ofthematsite2.Andalargeproportionofpatientssaidtheydidnotknowwhether
theyweresatisfiedwiththetreatmenttheyreceivedforcontinenceproblemsisthisbecauseofalackof
information?orbecausetheyareconfusedabouttreatment?

46


Characteristicsofleadership
Transformationalleadershipvstraditionalcommandandcontrolleadership
Thedatasuggeststheapproachtoleadershipwasautocraticwithdecisionsaboutcarebeingreferredbackto
thenurseinchargeoftheunit.TheNursingWorkIndexshowsthatnursesaregenerallyindifferentabout
autonomyorempowermenttomakedecisions.Thisreflectsalimitedunderstandingoftheroleofleadership.
Oneobserveroverheardcommentslike'IllhavetoaskSisterbeforeIcandothat'or'Sisterdoesnotlikeitif'.
However,thefocusgroupdiscussionsindicatedamoreproactiveapproachtoleadership.Onenurseleader
said'Wehavetheknowledgeandtheexpertiseandthewillingnesstodoitbutweneedmoremanpower.But
wearedoingalotofcontinencepromotionitsourphilosophy.'
Thestyleofleadershipinsomeinstancesclearlycontributedtoasenseofdisempowermentamongsomestaff,
asexpressedbyaparticipantatthefocusgroup:'Yousee,attheendofthedaywehavenocontrolover
decisionsaboutcareplansbecausethehelperscomeandtakethepatientsandhalfofthetimewedonteven
knowtheyareaway.Youcantreallyputtheburdenonus'.

Poororganisationalstructurevseffectiveorganisationalstructure
Theorganisationstructuresinplaceatward,unitorstrategiclevelcanhaveasignificantimpactonthequality
ofpatientcare.Forexample,inonewardareathenurseswereobservedcaringforanallocatedgroupof
patientsfortheirshift;thisprovidedcontinuityofcareandthepatientshadaccesstotheirnurse.Butin
anotherarea,thenurseswereonlyallocatedagroupofpatientsforearlymorningwashinganddressing;they
hadnospecificresponsibilityforthefollowthroughofcareandsomepatientsweredidnotreceivethe
continencecaretheyneeded.Thispatientscomment(fromRCPdata)illustrateshowtheorganisationofcare
affectsthedaytodayneedsofpatients:'ThewaterjustcomesfrommeifIleaveittoolongsoIwatchtheclock
andthencallthenursessotheycangettomeintime.IcatchoneastheywalkpastifIcantreachthebuzzer.
Somearequickerthanothersbuttheydotheirbest.Nothingissmoothandeasy.IaskedagesagoandnowIm
soaked.It'snotnice.Iamsorry'.
Thisisincontrasttotheorganisationofcarereportedinthisobserver'sfieldnotes:'Staffareallocatedtoa
groupofpatientsandappearverypersonoriented.Theyareconstantlycheckingwiththepatientthatwhat
theyaredoingorsayingisunderstoodandexplaininganactivityoradelay.'
Thetherapistsandthenurseshaveseparaterolesinrehabilitation.Thenursesareassociatedwithpersonal
carewhichisseparatefromtherehabilitationprocess.Thisleadsinsomeinstancestotheorganisationofcare
beingfocusedonthenursesgettingpatientsreadyfortherapy.
Thefollowingobservationwasalsomade:'The[occupationaltherapist]andphysiohaveseparaterolesfrom
thenurses.Thenursesworkaroundtheroutineofthetherapistbygettingthepatientsupandwashedand
dressedsothatthetherapistcando'rehabilitation'.
Sometherapistsclearlydifferentiatedtheirworkfromnursesrole.Oneoccupationaltherapistsaidinafocus
group:'Wetrytohaveadifferentphilosophytonursestogetthepatienttodoforthemselves.Nursesdont
havetospendfortyminutesonanADLwithsomebodywaitingforsomeoneslowlytodoit.Wehavetotrain
ourassistantsoutofrushingthepatients'.Thenursesfrequentlyassertedthattheirrolewasto'encourage'
ratherthan'do'.
TheRCPschemeauditshowedthatmostofthestipulatedguidelinesintheRCPaudittoolwerereadily
availableatoneunitinthisstudybutnotattheother.Clinicalnursemanagersthoughtthatthetoileting
facilitiesatbothsiteswereadequate.

47

Appendix4
Feedbacksheetforprepilottesting
Pleasecompletethequestionsbelow.Ifyoufindithelpfulyoumayalsomakecommentsonthequestionnaire
asyouarecompletingit.

1.Howlongdidittakeyoutocompletethetool?
2.Haveyouanyfeedbacktoprovideonthelayoutofthequestionnaire(e.g.wasiteasytofollow)?
3.Didyouunderstandwhateachstatementwasasking?Ifnot,pleasestatewhichonesyoudidnot
understand.
4.Didyoufindthatthestatementsreflectedthethemeofeachsection?Ifnot,pleaseexplain.
5.Wouldyousuggestanychanges?
6.Wereanyareasmissingfromthequestionnaire?
7.Wasthereanyduplicationofstatements?
8.Howwelldoyoufeelthequestionnaireachieveditsaim?
9.Whatdidyouthinkoftheoverallclarityofthequestionnaire?
10.Howhelpfulwastheintroductionandtheguidetousingthequestionnaire?
11.Canyousuggestanyimprovementstoincreaseclarityoftheintroductionandtheguide?
12.Wouldyouliketoaddanyothercomments?

Thankyouforprovidingthisfeedback.

48

Appendix5
Feedbacksheetforpilottesting
Pleasecompletethequestionsbelow.Ifyoufindithelpfulyoumayalsomakecommentsonthequestionnaire
asyouarecompletingit.

1.Howlongdidittakeyoutocompletethetool?
2.Whatdidyouthinkaboutthelayoutofthequestionnaire(e.g.wasiteasytofollow)?
3.Didyouunderstandwhateachstatementwasasking?Ifnot,pleasestatewhichonesyoudidnot
understand,andexplainwhy.
4.Didyoufindthatthestatementsreflectedthethemeofeachsection?
5.Wouldyousuggestanychangestoanyofthestatements?
6.Didyouthinkanyareasweremissingfromthequestionnaire?
7.Wasthereanyduplicationofstatements?
8.Howwelldoyoufeelthequestionnaireachieveditsaim?
9.Whatdidyouthinkoftheoverallclarityofthequestionnaire?
10.Howhelpfulwastheintroductionandtheguidetousingthequestionnaire?
11.Canyousuggestanyimprovementstoincreaseclarityoftheintroductionandtheguide?
12.Wouldyouliketoaddanyothercomments?

DEMOGRAPHICINFORMATION
Position:
Grade:
Dateofbirth(inordertoenabletrackingofresponsesovertime,pleaseindicatethefirstfourdigitsofyour
dateofbirthinthefollowingform,e.g.24thFebruaryis2402):__________

Thankyouforprovidingthisfeedback.

49

Appendix6
Interviewscheduleafterreliabilitytesting
Thankyouforagreeingtoparticipateinthisinterview.Itishopedthattheinterviewshouldnotlastmorethan
30minutes.ThequestionsbelowaresetoutasaguideonlyandshouldIthinkthatyouhavealreadyanswered
aquestioninresponsetoadifferentquestionthenthatquestionwillbeomitted.Theaimofthequestionsisto
gainyourviewsintheusabilityoftheContinenceAssessmentIndex(CAI)whichyouhaveusedinyourclinical
area.Theinterviewwillbetranscribedatthetimeitisbeingconducted.Thetranscriptswillbeheldinalocked
cupboardtowhichonlytheresearchteamwillhaveaccess.

JayneWrightandAliceCoffey,

Participantcode:

Date:

Interviewer:

WewanttoknowhowyouusableyoufoundtheCAI:
1.

Didyouunderstandwhateachstatementinthequestionnairewasasking?Ifnot,whichdidyounot
understand?

2.

Doyouhaveanysuggestedchangestoanyofthestatements?

3.

HowlongdidittakeyoutocompletetheCAI?Wasthisanacceptabletime(yes/no)?

ThenextsetofquestionsfocusesontheguidetousingtheCAI:
3.

CanyouexplainwhatyouseeasthepurposeoftheCAI?

4.

DidyoufindtheguidehelpedyouunderstandthepurposeoftheCAI?

5.

DidtheguideenableyoutounderstandhowtocompletetheCAI?

6.

Didyouthinkanythingwasmissingorneededtobetakenoutoftheguide?

WewouldliketoknowhowrelevanttheCAIistoyourownpractice:
7.

DidusingtheCAIhighlightanyissuesaboutyourpracticecontextthatyouwereunawareof?

8.

DidyoufindtheCAIrelevanttoyourclinicalpractice?

9.

IftheCAIwasavailable,wouldyouchoosetouseitinyourclinicalarea?

10.

Arethereanyothercommentsyouwouldliketoadd?

50

Appendix7
TheContextAssessmentIndex(CAI)andtheCAIguide
AbouttheCAI
TheaimoftheCAIistoenablehealthcareprofessionalstoassessthecontextwithinwhichcareisprovidedin
clinicalareas/teamsthatproviderehabilitationforolderpeople.Itcanbecompletedbyjustoneperson,such
asaspecialistorwardleader,oritcanbecompletedbyeachmemberoftheteam.

Context
Contextisdefinedasthesettingorenvironmentinwhichpeoplereceivehealthcareservices.Threeelements
havebeenidentifiedthatformthecontexttoensurethereispersoncentredpractice(McCormacketal2002.
Theseelementsare:culture,leadershipandevaluation.
TheCAIassessesthesethreeelements,andeachofthesehascharacteristicsthatcanbeassessedalonga
continuumfromweaktostrong(TableA1)Foraneffectiveculturethatisreceptivetochangeandhas
personcentredwaysofworking,thethreeelementsallneedtobestrong.
Eachelementisdescribedbrieflybelow.

Culture
Thecultureisseenasthewaythingsaredonearoundhere.Theculturecannotbeseenbutisbasedonthe
beliefs,valuesandassumptionsheldbythoseatanindividual,teamandorganisationallevel.Thecultureofa
practicesettingneedstobeunderstoodifmeaningfulandsustainedchangeandpersoncentredpracticeisto
beachieved(McCormack,2002).

Leadership
Thefocusofeffectiveleadershipisontransformationalleaderswhocreateaculturethatrecogniseseverybody
asaleaderofsomething.Theyinspirestafftowardsasharedvisionofthefuture,aswellasanumberofother
processessuchaschallengingandstimulating,enabling,developingtrustandcommunication(Schein,1985).
Transformationalleadershaveemotionalintelligence,rationality,motivationalskills,empathyandinspirational
qualities.Thesequalitiesmeanthatatransformationalleadercanalterthecultureandcreateacontextthatis
conducivetoinnovativeandpersoncentredpractice.

Evaluation
Theevaluationofpracticecantakemanyformsfromtheuseofharddata,suchascosteffectivenessand
lengthorstay,andsoftdatasuchasthepatientsexperienceofpractice.Inaneffectiveculture,the
healthcareprofessionalsuseevidencegatheredthroughavarietyofsourcestomakedecisionsaboutindividual
andorganisationaleffectiveness;thisevidenceisthenusedasanintegralpartofaccountabilityframeworks
andstaffappraisalstrategies.Thiscultureembracespeerreview,userledfeedbackandreflectiononpractice,
aswellasevidencederivedfromsystematicreviews,metaanalysisandauditofeffectiveness.Measurementis
avitalpartoftheenvironmentthatseekstoimplementevidenceintopractice.

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TableA1:Characteristicsofcontext
ELEMENTS

WeakcharacteristicsStrongcharacteristics

Context

Lackofclarityaroundboundaries
Lackofappropriatenessandtransparency
Lackofpowerandauthority
Notreceptivetochange

Boundariesclearlydefined(physical,social,cultural
andstructural)
Appropriateandtransparentdecisionmaking
processes
Powerandauthorityunderstood
Receptivenesstochange

Culture

Unclearvaluesandbeliefs
Lowregardforindividuals
Lackofconsistency

Abletodefineculture(s)intermsofprevailingvalues
andbeliefs
Valuesindividualstaffandclients
Consistencyofindividualsroleorexperiencetovalue:
relationshipwithothers
teamworking
powerandauthority
rewards/recognition

Leadership

Traditional,commandandcontrolleadership
Lackofroleclarity
Lackofteamwork
Didacticapproachestoteaching/learning/
managing

Transformationalleadership
Roleclarity
Effectiveteamwork
Enabling/empoweringapproachtoteaching/learning/
managing

Evaluation

Absenceofanyformfeedbackandinformation
Narrowuseofperformanceinformation
sources
Evaluationsrelyonsingleratherthanmultiple
methods
Poororganisationalstructure

Feedbackonindividual,teamandsystems
Useofmultiplesourcesofinformationonperformance
Useofmultiplemethods(clinical,performanceand
experience)
Effectiveorganisationalstructure

Benefitsofusingthetool
BycompletingtheCAI,youandtheteamyouworkwithinwillbeabletoassesswhetherthecontextinyour
clinicalareaisconductiveforpersoncentredpracticeandthelevelofreceptivenessofthecontexttochange
anddevelopment.Thetoolwillprovideevidenceofanychangesthatneedtobemadeinordertocreatea
strongcontext.
ThefollowingisaguidetousingtheCAI.Remember,aswithanythingthatisnew,itwilltaketimeto
learnandbecomeproficientin.
1.TheCAIcanbecompletedbyanyhealthcareprofessionalwhoisworkingwitholderpeopleina
rehabilitationsetting(inpatientoroutpatient)whohasworkingknowledgeofthearea.
2.Iftherearedifferentanswersfromdifferentteammembersthisdoesnotmeanthatonepersonisrightand
theotheriswrong;itsimplyreflectsindividualexperiencesofworkingwithintheclinicalarea/team.

Furtherreading
McCormackB,KitsonA,HarveyG,RycroftMaloneJ,TitchenA,SeersK(2002)Gettingevidenceintopractice:
themeaningofcontext.JournalofAdvancedNursing38(1):94104.

52

TheContextAssessmentIndex(C.A.I.)

UniversityofUlsterandUniversityCollegeCork.Nopartofthis
instrumentmaybereproducedwithoutpriorpermissionofthe
authors.PleasecontactProfessorBrendanMcCormack,Universityof
Ulsterbg.mccormack@ulster.ac.uk

53


Foreachofthefollowingstatements,pleaseputacrossinoneboxonly.
AStronglyagree;AAgree;DDisagree;SDStronglydisagree
Healthcareprofessionals(HCP)
SA

SD

01

PersonalandprofessionalboundariesbetweenHCPsaremaintained

02

Decisionsoncareandmanagementareclearlydocumentedbyallstaff

03

Aproactiveapproachtocareistaken

04

Allaspectsofcare/treatmentarebasedonevidenceofbestpractice

05

Thenurseleaderactsasarolemodelofgoodpractice

06

HCPsprovideopportunitiesforpatientstoparticipateindecisionsabouttheirowncare

07

Educationisapriority

08

Therearegoodworkingrelationsbetweenclinicalandnonclinicalstaff

09

Staffreceivefeedbackontheoutcomesofcomplaints

10

HCPsintheMDThaveequalauthorityindecisionmaking

11

Auditand/orresearchfindingsareusedtodeveloppractice

12

Astaffperformancereviewprocessisinplacewhichenablesreflectiononpractice,goalsettingandisregularlyreviewed

13

Staffhaveexplicitunderstandingoftheirownattitudesandbeliefstowardstheprovisionofcare

14

Patientsareencouragedtobeactiveparticipantsintheirowncare

54

15

Thereishighregardforpatientsprivacyanddignity

16

HCPsandhealthcaresupportworkersunderstandeachothersrole

17

Themanagementstructureisdemocraticandinclusive

18

Appropriateinformation(largewrittenprint,tapes,etc)isaccessibletopatients

19

HCPsandpatientsworkaspartnersprovidingindividualpatientcare

20

Careisbasedoncomprehensiveassessment

21

Challengestopracticearesupportedandencouragedbynurseleadersandnursemanagers

22

DiscussionsareplannedbetweenHCPsandpatients

23

Thedevelopmentofstaffexpertiseisviewedasaprioritybynurseleaders

24

Staffusereflectiveprocesses(e.g.actionlearning,clinicalsupervisionorreflectivediaries)toevaluateanddeveloppractice

25

Organisationalmanagementhashighregardforstaffautonomy

26

Staffwelcomeandacceptculturaldiversity

27

Evidencedbasedknowledgeoncareisavailabletostaff

28

Patientshavechoiceinassessing,planningandevaluatingtheircareandtreatment

29

HCPshavetheopportunitytoconsultwithspecialists

30

HCPsfeelempoweredtodeveloppractice

31

Clinicalnurseleaderscreateanenvironmentconducivetothedevelopmentandsharingofideas

55

32

Guidelinesandprotocolsbasedonevidenceofbestpractice(patientexperience,clinicalexperience,research)areavailable

33

Patientsareencouragedtoparticipateinfeedbackoncare,cultureandsystems

34

Resourcesareavailabletoprovideevidencebasedcare

35

Theorganisationisnonhierarchical

36

HCPssharecommongoalsandobjectivesaboutpatientcare

37

StructuredprogrammesofeducationareavailabletoallHCPs

56