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

3.11 - Summary - incentives and barriers to sustained implementation

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The essential ingredients for success identified by lead organisations in their progress reports and the factors identified by facility staff at the national workshops are not independent – it is reasonable to assume that each would have influenced the other in various ways. The results indicate that both groups support the importance of a receptive context (as defined for the evaluation), adequate resources and stakeholder engagement as important factors influencing the implementation of evidence-based practice. Likewise, the nature of the change in practice and having systems in place to support the use of evidence were not identified by either group as particularly important. Support for the other three factors used as the framework for the evaluation (having a model of change, demonstrable benefits of the change and staff with the necessary skills) was mixed.

The most important ‘key’ to the implementation of evidence-based practice during the EBPRAC program was leadership. This is consistent with evidence from the literature and the experience of the evaluation team from other evaluations (Eagar, Masso et al. 2008). Leadership came from various sources – facility managers, local facilitators, individual members of staff, members of project teams – but it had to come from somewhere. If leadership did not come from facility managers it was important that those managers were supportive of those who were providing leadership. For a useful summary, relevant to residential aged care, of the differences between leadership and management see Table 9 on page 30. It should not be forgotten that ‘improvement projects frequently fail in implementation and this is as much a management issue as a leadership issue’ (Masso, Robert et al. 2010, p 353).

A notable feature of the EBPRAC program was the motivation of many of the people involved. As with leadership, this came from various people but the critical group were the staff who had to change their practices. If they did not ‘come on board’ with what the projects were trying to achieve then the likelihood of changes being implemented and sustained were very much reduced.

Considerable resources were spent educating staff (for details see Section 5.1) and the approaches used, with a focus on targeting the needs of individuals and small groups, were consistent with what has been shown to achieve the best results (see Section 4.4). However, education can only take things so far. Knowledge is a necessary pre-condition for change to occur but is insufficient on its own to change behaviour. The projects demonstrated that it was important for staff to be able to ‘see’ the benefits of what they are being asked to do and to understand why changes were necessary. This was more important than simply being told that there was ‘evidence’ to support a change taking place. Many of the changes involved additional work, at least initially, which was difficult to incorporate into a pattern of daily work characterised by ‘busyness’ and lots of routine.

All of the EBPRAC projects invested considerable time and energy in communication of one form or another – between members of the project consortia, between project leads and facilities, and within facilities. There was a general sense that informal communication (chat, talk, conversation) between those working in the facilities could be very influential:
It’s having conversations with our staff about how they can approach things differently, what might have been a better way to do it, that sort of stuff. (F)
They were talking about the project all the time. (F)
Communication across shifts and between levels of staff was almost always problematic because opportunities to talk are very limited. (T4)
Residential aged care has a high proportion of part-time staff, not only in terms of the number of days worked per week but also in terms of the number of hours worked per day, which can make it difficult to get good attendance at formal meetings. A recent paper has indicated the importance of conversation as an influence on implementation and argued that ‘instead of thinking of intervention implementation as a problem of reliable transfer, we would be better off to think of it as a problem of sensemaking and learning (Jordan et al 2009).

The lessons learnt from the EBPRAC program about how to implement evidence-based practice have been incorporated into a series of ‘principles of practice’ to be found in the chapter on generalisability (Chapter 6).
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