5 Discussion
5.1 Adapting knowledge to local context
A starting point for this thesis was to design and develop a leadership intervention to support managers in quality and safety work in nursing home and homecare services (Paper I). The translation of knowledge into healthcare practice is complex and not a straightforward process (Barwick et al., 2020; Straus et al., 2013; Wensing & Grol, 2019). For this reason, in the initial phase we identified the contextual challenges (Ree et al., 2019; Wiig et al., 2019), and Paper I illustrates how this was carried out in a longitudinal process with multiple input and involvement from diverse user representatives, pilot testing and further adaptations (language, shortage of text, change of original quality challenge) to make the leadership guide suited to the practical challenges facing managers in Norwegian nursing homes and homecare services. The action phases in the KTA framework guided our process and contributed key insights into the perspectives, barriers, and processes that our knowledge translation action cycle needed to incorporate (Graham et al., 2006).
Lessons learnt, for example for regulatory bodies or national campaigns aiming at implementing research into practice (standards, tools, guidelines, checklists), is to take time to understand the context and possible adaptations to make these as relevant as possible. These processes are time consuming.
Assessing barriers and facilitators of knowledge translation
Learning does not occur automatically with the simple dissemination of a tool, such as the leadership guide; it usually requires effort to support
the translation with a targeted intervention program (Davies & Edwards, 2013; Straus et al., 2013). There are several reasons for the barriers between valid recommendations of guidelines and delivery of care based on this evidence. Active involvement of the end-users of the leadership guide led to significant changes in our study (e.g., professional language, learning tools) which echoes other literature in the field (Malterud et al., 2020; O`Hara et al., 2019a; O`Hara et al., 2019b; Vindrola-Padros et al., 2016). Assessing barriers to and facilitators of knowledge use is closely linked to the adaptation and uptake of evidence (Colquhoun et al., 2013;
Davies & Edwards, 2013). In the intervention design, this was based on knowledge of barriers and facilitators among the future users of the guide involved in the design and development phase (Paper I). For example, videos with examples were recommended, short 2-hour workshops, homework between workshops, feedback on survey results, and getting access to all intervention materials were based on the intention to facilitate knowledge use among managers in their daily operation where they have limited time (Paper I). All of these intervention components were developed to circumvent barriers and to tailor the intervention.
Monitoring and sustainability of the leadership intervention
Monitoring of interventions is important to determine how and to what extent knowledge has been picked up by the end-users (Straus et al., 2013). The workshop program that we developed for implementation and monitoring of the leadership guide included similar workshop agendas, learning resources and guide content (Paper I). This enabled researchers to observe the implementation of the leadership guide and monitor its influence on quality and safety work practices in nursing homes and homecare services (Paper III). Monitoring systems and feedback mechanism are needed to determine relevant process and factors to access sustainability (Straus et al., 2013), although, sustainability of improvements has been recognised as a challenge for some time (Fleiszer et al., 2015; Shelton et al., 2018), However, there is
agreement that sustainability requires thoughtful planning, attention and should be initiated early in the design and planning of interventions (Davies & Edwards, 2013; Lennox et al., 2020). The KTA framework emphasises sustainability in knowledge translation processes (Davies &
Edwards, 2013). We addressed sustainability in the intervention design by timing our intervention workshops, adding a fourth workshop on sustainability six months into the intervention and a check-up call between the third and fourth workshops to follow up with managers on their use of the leadership guide and to answer technical questions about the web version (Paper I). Sustainably, is however, closely linked to the multiple challenges facing managers in nursing home and homecare services. There is pressure to provide healthcare services to more and sicker patients (Gautun & Syse, 2013; Gautun & Syse, 2017; Glette et al., 2018). As argued by Dixon-Woods (2019) the success of improvement depends not just on the interventions, but also on environment: improving processes may take us so far, but stops if the basics of structure and resources are not in place. This is supported by a recent study that concludes that the shift in healthcare culture towards person-centredness requires not only full commitment on the part of managers but also adequate financial and human resources (Asante et al., 2021).
A need to emphasise stakeholder involvement in knowledge translation processes
There is also increased pressure to translate and adapt research-based knowledge to practice (Straus et al., 2013), and healthcare programmes and interventions are increasingly implemented at the front lines of care to increase effectiveness and efficiency (Braitwaite et al., 2020). Several frameworks can guide and structure implementation processes and uptake of knowledge in practice (Rycroft-Malone & Bucknall, 2010).
The Consolidated Framework for Implementation Research (CFIR), for example, offers a list of constructs to consider before implementation
(McDonald, 2013). Our use of the KTA framework guided the knowledge translation process with specified action phases to enable implementation and its effect on managers’ practice. Researchers have focused more on the importance of interactions between researchers and knowledge users in predicting the uptake of knowledge (Bowen et al., 2013). Embedding implementation science and healthcare service researchers into the healthcare system is a promising strategy to improve the rigour and sustainability of interventions (Aase et al., 2021a;
Braitwaite et al., 2020). In this thesis, the co-researchers, affiliated with the SAFE-LEAD project, linked research to practice, contributing professional language in the practice field and knowledge about organisational processes in the nursing homes and homecare settings (Aase et al., 2020). The embedded researcher in the organisation allows for the creation of informal processes and coproduction of knowledge that can lead to greater ownership of research findings and anticipate sources of tension produced by competing views (Garfield et al., 2015;
Malterud et al., 2020; Marshall et al. 2014; O`Hara et al., 2019a; O`Hara et al., 2019b; Rowley et al., 2012; Staley, 2015; Tritter, 2009; Vindrola-Padros et al., 2016). The co-researchers contributed in-depth contextual knowledge and expertise in workshops and were able to link managers’
quality and safety challenges and reflections to the possible use of the leadership guide and thereby increase the sustainability (Papers I, III).
Embedded research can strengthen the knowledge use in practice by increasing the usefulness for the intended users (Garfield et al., 2015;
Malterud et al., 2020; Marshall et al. 2014; O`Hara et al., 2019a; O`Hara et al., 2019b; Staley, 2015; Tritter, 2009; Vindrola-Padros et al., 2016).
The thesis demonstrates the importance of knowledge about local context when implementing leadership interventions to access facilitators for and remove barriers to implementation. The co-researchers and managers contributed with their contextual adaptation of the leadership guide and adaptation of the intervention program to ensure relevance and usefulness for the managers in their everyday practice (Paper I). Although the use of participatory approach creates
opportunities, researchers need to remember that time constraints for the involved staff could be a possible barrier to their engagement with research (Marjanovic et al., 2019).
The KTA framework and possible further iterations
Diffusion of knowledge is often described as a passive effort that requires active dissemination (Field et al., 2014; Straus et al., 2013). We used the action phases provided by the KTA framework as a guide to the active dissemination and translation of the leadership guide. The thesis shows the comprehensive work needed to translate knowledge into practice and the importance of context adaptation of tools and intervention activities (Papers I, III). However, a systematic review by Field et al. (2014) found the use of KTA to have varying degrees of completeness, often related to the monitoring and sustainability of knowledge use in practice. Considering the longitudinal focus on translating knowledge into practice (Paper III), use of the leadership guide still depended on management continuity in the organisations and was vulnerable to externally driven changes (Paper III). Therefore, based on the thesis’ findings on could argue that the KTA framework should focus more on the temporality of implementation and sustainability. It is possible to claim that it lacks a clear description and emphasis on how to involve stakeholders over time to succeed with knowledge translation in practice and that the continuous role of user involvement is not so visible in the KTA framework. This is corroborated by our finding of management continuity to be crucial for implementing the leadership guide regardless of the context adaptations of both the intervention program and the leadership guide. As our research demonstrated how important management continuity was and this is also a possible iteration of the framework. Therefore, the continuity of managers should be pinpointed for future use of the KTA framework and in the operationalisation of tools in healthcare practice when translating knowledge into practice among managers and employees. This demonstrates possible further refinement of theoretical frameworks
guiding knowledge translation to new contexts in healthcare such as nursing homes and homecare. Such frameworks need to reflect the importance with the management continuity element to a stronger degree than today.
5.2 Multiple challenges in quality and safety work