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

3.5 - Context for change

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The definition of a receptive context for change used for the evaluation includes factors such as leadership (including informal leaders), the existing relationships between staff, a climate that is conducive to new ideas and the presence of a recognised need for change. Reference to the influence of ‘context’ occurs repeatedly in the literature, including the idea that what works in one context may not work in another (Kitson, Harvey et al. 1998; Dopson, FitzGerald et al. 2002); that implementation may be more context-dependent for some interventions than for others (Øvretveit 2004); or that some contexts may be more receptive to change than others (Pettigrew, Ferlie et al. 1992; Greenhalgh, Robert et al. 2004).

Dopson et al (2002) identified a set of factors for a receptive context, including appropriate infrastructure and resources, pressure for change, a supportive culture, sharing information and clear goals for change. Gustafson et al (2003) refer to a ‘tension for change’ and the need to adapt changes to fit existing culture and practices. Implicit in the literature is that context is not some inert background to what people do but interacts with staff and the systems within which they work in many different ways (Fitzgerald, Ferlie et al. 2007).

This section explores some of the components of the context for change, as it applies to the EBPRAC program.

3.5.1 Leadership and management support

The literature indicates that leadership in the management of change is of crucial importance (Gustafson, Sainfort et al. 2003; Walter, Nutley et al. 2003). It is worth noting Shanley’s research into the management of change by facility managers which found that most managers in residential aged care learn to manage change ‘through on-the-job experience, which has considerable limitations as a form of learning’ and that ‘many managers in the sector do not get appropriate training and support in the management of change’ (Shanley 2007, p 997).

All projects identified the importance of either leadership from senior managers or management support, with the presence of either of those two factors helping implementation and the absence of leadership or management support hindering implementation. Management support did not necessarily entail a lot of active involvement but did include things like sanctioning the attendance of staff at education programs, being seen to support local facilitators, 'fixing' problems that couldn’t be solved by staff or the project team and generally letting their own motivation inspire others:
Whoever is your champion … is very crucial to the success of it but it’s obviously really important to have that organisational support as well. (P)
If they don’t have supportive management at any level, it’s a dead duck in the water, because it just meets brick walls all the time. (P)
Whether it is framed as ‘leadership’ or ‘management support’ a critical element in supporting implementation has been that there is more than one person involved. Leadership can come from one source but is fragile if it does e.g. the leader leaves, takes on a new role or has insufficient time to provide the leadership required. Most facilities only have a small number of leadership positions but the various positions nominated as being sources of leadership (facility managers, staff appointed to formal facilitator positions, informal leaders, quality managers) indicates the importance of having a system of leadership and support:
There have been differences in progress across facilities. This appears to reflect the level of motivation of the (resource nurse) in combination with the level of support from the facility’s management. If both of these occur there seems to be great progress in project activities. If only one of these factors is present then the project will progress but perhaps not as quickly, and possibly with additional support required from the project’s management, such as meeting with facility managers. In facilities where neither factors are present, there are major barriers to progressing project activities. (T3)
Significant involvement from the Director of Nursing in spearheading involvement in face to face training and completion of e-learning led to significant staff participation. The champion was supported by the quality manager, who has taken responsibility for the sustainability of the program and practices implemented. (T4)
Two out of three of the facilities are very, very supportive and the third one, their care person was actually a part time worker so sometimes it was difficult as they juggle things … But in that particular facility their director of HR and then from the other registered nurses actually came on board ... rather than it just depending on one person they had then three people that could be involved in it, kept and maintained. (P)
There are many different types of leadership, and a vast literature on the subject. What came through from the interviews with those involved in the projects was the importance of having leaders with a wide range of skills, including excellent interpersonal skills. This is summed up in the following interview with two people (A1 and A2) who identified two of the facility managers in their project as ‘outstanding’ and when asked ‘what made them outstanding’ responded as follows:
(A2) They were interested and committed.
(A1) Yes they both run facilities where you think, “Well if I had to go to an aged care facility I would want someone like that running it.” They’re compassionate but they’re also fairly tough, like the way that they manage staff and so that they’re fair people, very compassionate and…
(A2) Willing to try something new.
(A1) Yes, and always friendly, cooperative, yeah just good people really to work for, good to work for…
(A2) But would still have the dialogue if they didn’t agree with something or…
(A1) That’s right.
(A2) As a collegial approach.
(A1) And both obviously with a lot of nursing experience and a lot of managerial experience as well … people that we got to know on a personal level just through our interaction with them. (P)
Resistance or overt lack of support from facility managers was uncommon. More typically, lack of support was due to competing priorities. Turnover of facility managers was reported as having an adverse impact on implementation by eight projects, primarily the lack of continuity resulting from the change of manager and the need to orientate the new manager to what the project was about:
In each facility major managerial changes occurred over the 14 months of mentoring, and each case left the staff and facility with a period of uncertainty, followed by some months of adjusting to new leadership styles. (T4)
For two projects the turnover of facility managers was considerable, in one case affecting 9 out of the 10 facilities in the project. One facility in another project had four different directors of nursing over the course of their project.

There is considerable debate in the literature about what is meant by the terms ‘leadership’ and ‘management’ but both are important for the implementation of change. Table 9 includes a useful summary of the distinction between the two, based on a review of the literature specific to residential aged care (Jeon, Glasgow et al. 2010).
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Table 9 Elements of leadership and management

Elements of leadership	Overlapping elements of leadership and management	Elements of management
inspiration, transformation, direction, trust, empowerment, creativity, innovation and motivation	communication, decision-making, integrity, role model, negotiation, professional competence and setting standards	delegation, performance, planning, accountability, finance, teamwork and team building, monitoring and evaluating, formal supervision and control

Note: This table is taken from the paper by Jeon et al (2010) entitled Policy options to improve leadership of middle managers in the Australian residential aged care setting: a narrative synthesis.

The role of senior management and how this links with organisational culture is well-illustrated by this comment from one of the project final reports:
Two facilities have been highly successful in maximising participation in the consortium to build capacity in their staff and move towards more dementia friendly physical and social environments in a sustainable way. In these organisations the existing culture was compatible with the person-centred philosophy of care underpinning the development of dementia friendly environments. Person-centre care is core to their mission and their approach to participation was one of a vision of long term sustainable change, not just a project. Senior management was open to doing things differently and utilised the resources provided to support staff participation. (MU behav final report, p 48)
The same project concluded that successful implementation was found in those facilities where ‘flexible responsibility was the dominant component in management’, characterised as:
senior management delegated widely and supported those delegated in their responsibilities to effect change. This facilitated team work and under this management, significant numbers of staff were involved in the change process. (MU behav final report, p 50)
The term ‘clinical leadership’ is frequently used in health care to identify the need for leadership from clinicians. The complex clinical needs of many residents mean that the term is also applicable to residential aged care. However, the term ‘clinical’ can have very unclear boundaries. Providing adequate nutrition, for example, can be driven by some very clinical reasons but is also simply part of providing a good service. Pain management requires clinical leadership but for something like the implementation of person-centred care the word ‘clinical’ seems inappropriate. The application of moisturiser after showering residents, a key change in the wound management project, is usually not thought of as ‘clinical’. One of the issues in residential aged care is that clinicians with the most knowledge and expertise (registered nurses and general practitioners) have the least involvement in the day-to-day care of residents.

It is useful to think in more general terms about the need for leadership, of which clinical leadership is an important part, with the source and type of leadership varying with the context and the content of change. That leadership might come from a manager, a registered nurse, an enrolled nurse, a personal carer or other category of staff (e.g. allied health). It is the qualities that count, not the position a person holds, as these examples from eight different projects illustrate:
(Names of two personal carers) are really leaders in their areas, and people listened to them, and it was a way to get information across without being bossy or stand overy or anything like that. It was hey, you know this? (F)
Generally they had one (champion) who was a registered nurse so if that registered nurse advocated it then that was generally well taken up and it was usually driven by a (champion) or someone who was interested in the whole idea and wanted to push it forward. (P)
You’ve got to have that one key person I think who’s really good, who’s really clinically switched on too … you’ve got to have a good driver at the top. (P)
You need good leadership, people who can turn that negative stuff around and give good argument for why change is really necessary, it's not really a choice. It's the way they communicate. (F)
We found that we had two Division 2 nurses who have great leadership and respect amongst the staff and are able to bring about change in a non-confrontational way. (F)
My resource nurse was an absolute star. There’s not a question about it. (Name of resource nurse)’s leadership and enthusiasm for the project was infectious to begin with. (F)
Somebody has to keep driving it or co-ordinating it and doing the hard work. (F)
The leaders are the ones who can push the staff, who aren’t frightened to up them, to reprimand and drive, challenge them, reprimand them really. If you don’t do this well whatever, whatever. Because if they don’t do that then the whole team doesn’t get driven, we don’t have the time. (F)
Leadership was a recurring theme, not only amongst those involved in the projects, but also amongst the ‘high level’ stakeholders interviewed for the evaluation (see Section 11.5). The importance of leadership was illustrated at one of the EBPRAC national workshops when participants from 60 residential aged care facilities ranked leadership as the second most important factor (after adequate resources) influencing the implementation of evidence-based practice (see Appendix 15).
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3.5.2 Need for change

One component of a receptive context for change is the need for change. In general, projects did not frame the ‘need for change’ in their funding submissions in terms of the situation in participating facilities. Rather, ‘need’ was identified with reference to the literature which talks in terms of general needs in residential aged care. Some participating facilities included details about need in their letters of support to be involved and for one project the topic was chosen by one of the participating providers in recognition of the fact that the area of practice needed some development.

In general, lead organisations chose to work with particular facilities for various reasons: facilities they thought would be receptive to the program; facilities they had worked with previously; facilities where implementation was likely to be more challenging; facilities suggested as a result of personal networks. The facilities participating in the 13 EBPRAC projects may have had less ‘need to change’ than some others that did not participate.

The general picture, from both the perceptions of those working on projects and the results from baseline audits conducted by some projects, was one of building on what had gone before rather than needing to make dramatic changes:
Our model of care came first and the EBPRAC project I saw as building on and giving more in depth knowledge and support to the staff on top of that. (F)
We already had ideas about we knew we had to improve things. So we knew we had to target specific people and really look at their patterns. We’d already started that prior to the project. (F)
I think the beauty of this one is that it coordinated everything together, and probably updated a lot of the paperwork that we were using in the past, and just making it a bit better in that way. I think prior to coming palliative care was done pretty well, it’s just documentation probably needed to be updated, and the system of how it was delivered. (F)
In terms of environment and care quality, there was little room for improvement in each of the seven participating care units … because many of the domains were close to the ceiling at pre-evaluation. (T4)
This is consistent with what is reported elsewhere in this report about the changes implemented as part of EBPRAC being incremental in nature (Section 3.5.3). The changes were relatively small in scope, suggesting that the 'need for change' was not a particularly strong driver of change. However, an interesting aspect of these incremental changes is that although many seem to be quite minor there has to be recognition in the first place that something needs to be done, or that something can be done, to bring about an improvement. The projects played an important role in bringing about that recognition:
They weren't aware that wounds were such a big problem. (P)
We thought we were giving good oral care and it was obvious we weren’t. (F)
One area where this was particularly important was in promoting a physical environment to support behaviour management. In one behaviour management project the need for change was described as a ‘key factor’ in bringing about modifications to the physical environmental. Another of the behaviour management projects noted that physical environments ranged from those that were very poor to new purpose built facilities.

3.5.3 Capacity for change

An important dimension of context is the nature of daily work. Residential aged care facilities are busy places, with a tendency to revert to ‘routine’ to cope with that workload and little capacity to introduce anything that is seen to be additional. Much of the work ‘has’ to be done:
I think they’re very adaptable to change however they are also very task driven in regard to the fact that that’s how they cope with their stress, they have high workloads … their method of dealing with that work stress is routine. (F)
The reality of say an afternoon shift is, there’s 20 residents this end and 20 residents that end that need to be – we need to make sure they’re fed, we need to make sure they’ve been toileted, that they’ve had a bit of a wash, they’ve got their nightgowns on, they’re comfortable. You still have to actually do that work. It still has to be done. (F)
They’re so used to just being so task focused and going back to what their routine is and they have such a routine. (F)
This is what we’re talking about, this embedding this kind of idea, busy or not, they have to take five minutes out to pull up a chair, sit down, engage that individual in conversation while they’re providing some nutrition; it’s about an eating experience, it’s not about shovelling nutritional intake into them. (P)
When everything is going ‘right’ things are fine but it doesn’t take much to upset the equilibrium of a ‘good day’:
When things start going wrong, there doesn’t seem to be enough staff. (F)
On a great day when your team’s great, residents are quite settled today, it’s sunny, there’s no noise, it’s quiet, you know, everyone ate – everyone went to the toilet when they took them – all those sorts of things. They have a great day, they love it, when it’s been a really good day they can spend one to one time. On a day like when you get a new resident who might be more aggressive or someone stripping or things start to unravel for them and they start to feel they’ve lost a bit of control, that’s when they seem to slip out of person-centred focus, get them up, they’ve got all of them, do this, do that, get them out – you can just hear them talking, you can see them rushing and I think that’s where it falls apart. (F)
The experience of those involved in the EBPRAC program was that the capacity for change was not large, requiring careful consideration to be given to what changes were introduced and how those changes were introduced. Interviewees described the process of change in different ways but typically characterised it as incremental in nature, with a need for ‘small changes over a period of time’, making changes ‘in step-wise progression’, breaking changes down into ‘bite-size chunks’, bringing about change ‘in stages’, with a need to ‘chip, chip, away slowly’. This is not to say that small changes can’t accumulate over time into something more significant:
Sometimes they didn’t really realise how much they had done, because it had happened over the span of a year, it was somewhat subtle. (P)
This way of describing change presents a basic paradox – on the one hand change is incremental but residential aged care as a sector is one that appears to be in a constant state of change.

Based on what was said in interviews and reported in progress reports change in residential aged care can be conceptualised as having four levels, summarised in Table 10.
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Table 10 Levels of change in residential aged care

Level of change	Scale of change	Source of change	Planned or unplanned	Frequency of change	Examples of changes
Level 1	Large-scale	Primarily external	Typically planned	Infrequent	Changes to funding system, change of facility ownership
Level 2	Medium-scale	Primarily internal	Combination of planned and unplanned	Relatively frequent	Change in key staff member, implementation of a new record system, planned move to a new model of care
Level 3	Medium to small-scale	Internal	Usually some degree of planning but can also be quite spontaneous	Relatively frequent	The level at which most quality improvement takes place The level at which implementation of evidence takes place
Level 4	Small-scale	Internal	Unplanned	Frequent	A new resident, a new member of staff, ‘one off’ incidents on a particular day, small changes to daily routines

Not everything will fit neatly into the levels described in Table 10 but it is a useful way of thinking about what occurred. The EBPRAC projects were generally trying to implement changes at Level 3 but had no control over the changes that were happening at levels 1, 2 and 4. Changes at these other three levels, particularly levels 2 and 4, had a major impact on what the projects were trying to achieve, with the most commonly reported changes being turnover of facility managers (Level 2) and turnover of facility staff (Level 4). Further details of the impact due to turnover of managers are included in Section 3.5.1.

The following examples from five different projects illustrate the point about change at one level influencing what goes on at the ‘project level’ of implementing evidence-based practice:
One facility has had a change in resource nurse as well as the facility manager and this has disrupted progress substantially. (T3)
A continual high rate of aged care staff turnover has disrupted continuity of the project and requires continuous re-education and re-engagement with the project. (T3)
Implementation period extended due to multiple unpredictable events, including sickness absence of Care Service Manager, accreditor visits and a period of ‘lock-down’ of the facility due to infectious disease. (T3)
Change comes from two sources. One is the residents themselves because every time a new resident comes in the routine has to be changed … there’s also the changes bought by new members into the work team so there’s that group dynamics, the testing of the group that’s going on out there until that member’s accepted so those changes are out there for them all the time. Then there’s the changes enforced on us from above. (F)
There’s always small change, like change in staff, change in leadership – we’re having a major change at the moment, we’re going through a restructure. So our management has changed and that’s really had an affect on staff … I think there’s always changes, our residents change. (F)
This conceptualisation of change not only has implications for understanding what helped and what hindered the projects in implementing evidence-based practice but also indicates the challenges faced by facilities undertaking day-to-day practice improvement.

3.5.4 Characteristics of individuals

Many different ways were used to describe people with positive attitudes towards the changes implemented in EBPRAC e.g. motivated, committed, enthusiastic. The importance of having enthusiastic facilitators has been referred to elsewhere in this report (see Section 3.3.3) but enthusiasm/motivation played a critical role more broadly:
The only reasons things are successful is that I have some staff that go way over and beyond. (F)
The key to any project is finding those people who are enthusiastic and very often change does come down to someone who is motivated to take on a role. (P)
Directors varied in their level of commitment to the project … the ones who are more heavily committed to the project and took more of interest were probably our better performing facilities and certainly that was easier for us to interact with them there. (P)
That other facility that improved the most. Their director of nursing was probably the most enthusiastic about it all as well. (P)
The staff were enthusiastic so we were all onside and ready to go and it’s been a most beneficial project for us. (F)
The best way to get people on board is to be enthusiastic about it and I have to say I really was because it was my passion. I was very keen to be involved in this project. (F)
It seems that those who are making most progress appear to be highly dedicated and motivated staff, who report that they undertake some of the project work in their own time. ( T3)
You can do anything if you’ve got the right attitude (F)
Motivation is but one part of a broader set of individual characteristics that were ‘key’ factors influencing implementation during the EBPRAC program, including the beliefs held by individuals about their own capabilities, as well as levels of knowledge, skills and literacy.

Figure 1 gives an indication of the importance of these characteristics amongst the three main groups of staff – managers, facilitators and the remainder of the facility staff. There is a need for caution in interpreting the figure as it simply gives a count of the number of data sources (an interview or a project progress report) where motivation or any of the other characteristics are mentioned. However, the figure is consistent, in general terms, with more in-depth analysis. Motivation is the most important of the characteristics for all three groups; knowledge, skills and beliefs about their own capabilities are important characteristics for facilitators and facility staff (people won’t do something if they are not confident they can do it), and literacy is an issue confined to facility staff.
Figure 1 Characteristics of individuals

The information below is a description of data provided in Figure 1 above

Number of data sources
Facility staff

• Literacy - 9
• Skills - 9
• Knowledge - 14
• Beliefs about capabilities - 19
• Motivation - 35

Facilitators

• Skills - 3
• Knowledge - 5
• Beliefs about capabilities - 8
• Motivation - 25

Facility managers

• Knowledge - 2
• Beliefs about capabilities - 1
• Motivation - 21

The role played by these characteristics was not one of the ‘key success factors’ identified in the initial literature review although individuals are an important part of some of those factors, particularly a receptive context for change and stakeholder engagement, participation and commitment. This finding about the influence of individuals is consistent with an important review of the theoretical literature, published since the evaluation began, which developed a ‘meta-theory’ consisting of five domains, of which one is ‘characteristics of individuals’ (Damschroder, Aron et al. 2009).

As with much of what took place in the EBPRAC projects there were close links between being motivated and enthusiastic and factors such as stakeholder engagement (Section 3.9) and demonstrable benefits (Section 3.6). Some staff were motivated from project commencement, some staff became ‘engaged’ (and motivated) later on as a result of receiving some education, others ‘saw’ the benefits of the changes taking place and then became enthusiastic about what was going on.
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