Encouraging Best Practice in Residential Aged Care Program: Final Evaluation Report

6 - Generalisability

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For the purposes of this evaluation generalisability was defined as ‘are your lessons useful for someone else?’ Generalisability thus involves consideration not just of the ‘lessons’ but of some mechanism for linking those lessons to someone (or somewhere) else. With experimental research this is done by taking a sample (preferably a random sample) from a population and then using statistical tests to identify whether the results obtained from the sample can be generalised to the population. This is not relevant for the EBPRAC program.

The other way of considering generalisation, which is relevant to the EBPRAC program, is to use a particular theory as the way of linking what happened in one place (e.g. in a particular project) to what might happen in another place (facilities in the rest of residential aged care), known as analytic generalisation (Yin 2003). None of the EBPRAC projects used a theory to link what they did with what might happen elsewhere in residential aged care. Project final reports did not address the issue of generalisability, other than to comment in some cases that the various resources developed by projects (e.g. educational materials, tool kits) could be use elsewhere in residential aged care.

Projects ranged from those that were relatively prescriptive about what needed to be done (e.g. a palliative care project which implemented palliative care case conferences, a pain management project that implemented a pain assessment tool) to those with more latitude about the ‘what’ of change e.g. the two projects in Round 1 that adopted an action research approach to facilitate practice changes. To a degree, ‘what’ changed varied according to individual facilities – something may have already been in place or may not have been ‘needed’. In general though, ‘what’ changed varied less than ‘how’ changes were implemented.

Rather than developing a theory the lessons learnt during the EBPRAC program are presented here as a series of ‘principles of practice’ which should be ‘useful for someone else’, although still requiring adaptation to particular settings (Patton 2002). Research on improvement initiatives in the United Kingdom warns that information about how something worked elsewhere does not constitute knowledge about how to implement it in one’s own organisation (Bate and Robert 2002). The strength of these ‘principles of practice’ lie in the fact that the principles have been derived from a diversity of different cases (projects), using different strategies to change practices, in a variety of settings (facilities of differing size, ownership and location) and areas of clinical practice. The principles are derived from data collected from many sources, with reference to the available literature:

• Leadership - without someone to lead change it is probably not worth starting. One person might be able to start the change but it takes more than one leader to keep going. Leadership does not have to come from managers but if that is the case it is important that managers support the change.
• Staff motivation - the motivation of individuals working in residential aged care is one of the ‘keys’ to successful implementation.
• Change advocates - involving the people who will be affected by any change is important. Strong advocates for change may come from staff who would not normally be considered change agents.
• Evidence - simply having ‘evidence’ is not sufficient. Staff will want to know whether the proposed changes ‘make sense’ and will work i.e. provide benefits for themselves, their colleagues or residents.
• Education - education is necessary but not sufficient to change the practices of those providing care to residents. Education needs to be done in tandem with other strategies and tailored to the knowledge, skills and literacy levels of staff. A ‘one size fits all’ approach to education is likely to be ineffective.
• Communication - informal communication such as conversations and impromptu meetings can be just as important as more formal means of communication.
• Capacity to change - the capacity to implement evidence-based practice in residential aged care is limited, resulting in change that is likely to take place ‘step by step’ and in small doses rather than change on a more radical scale.
• Planning - some form of plan for implementing evidence-based practice is generally a good idea, but there is a need for flexibility to cope with unpredictable events that can upset those plans.
• Resources - resources are required, usually in the form of resources to provide education or to ‘free up’ at least some staff time to support change.

In stating these principles there is a need for caution. The principles have arisen out of a program where the circumstances for bringing about change differ significantly from what might be found in day-to-day practice:

• Each project was allocated considerable resources and reasonable ‘lead times’ before implementation commenced.
• Lead organisations selected facilities to work with, often based on existing working relationships and networks.
• The facilities involved in EBPRAC may not be representative of facilities throughout residential aged care.
• Considerable sums of money were spent on education which would not normally be available to facilities.
• Lead organisations had considerable expertise, not only about the content of change (the evidence) but the process of bringing about change. This element of leadership is not available to those trying to implement evidence-based practice outside a project environment.

Most of the practice changes implemented in the EBPRAC program could be implemented throughout residential aged care but this would depend on the availability of sufficient resources and contextual factors such as leadership, with some adaptation to meet local circumstances and the learning needs of staff.
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