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      Process of implementing and delivering the Prevention of Delirium system of care: a mixed method preliminary study

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          Abstract

          Background

          Delirium is a frequent complication of hospital admission among older people. Multicomponent interventions which can reduce incident delirium by ≈one-third are recommended by the National Institute of Health and Care Excellence. Currently, a standardised delirium prevention system of care suitable for adoption in the UK National Health Service does not exist. The Prevention of Delirium (POD) system of care is a theory informed, multicomponent intervention and systematic implementation process which includes a role for hospital volunteers. We report POD implementation and delivery processes in NHS hospital wards, as part of a feasibility study.

          Methods

          A comparative case study design and participatory, multi-method evaluation was performed with sequential six month preparatory and six month delivery stages. Six wards in five hospitals in Northern England were recruited. Methods included: facilitated workshops; observation of POD preparatory activities; qualitative interviews with staff; collection of ward organisational and patient profiles; and structured observation of staff workload.

          Results

          POD implementation and delivery was fully accomplished in four wards. On these wards, implementation strategies informed by Normalization Process Theory operated synergistically and cumulatively. An interactive staff training programme on delirium and practices that might prevent it among those at risk, facilitated purposeful POD engagement. Observation of practice juxtaposed to action on delirium preventive interventions created tension for change, legitimating new ways of organising work around it. Establishing systems, processes and documentation to make POD workable in the ward setting, enhanced staff ownership. ‘Negotiated experimentation’ to involve staff in creating, appraising and modifying systems and practices, helped integrate the POD care system in ward routines. Activating these change mechanisms required a particular form of leadership: pro-active ‘steer’, and senior ward ‘facilitator’ to extend ‘reach’ to the staff group. Organisational discontinuity (i.e. ward re-location and re-modelling) disrupted and extended POD implementation; staff shortages adversely affected staff capacity to invest in POD. Findings resulted in the development of ‘site readiness’ criteria without which implementation of this complex intervention was unlikely to occur.

          Conclusions

          POD implementation and delivery is feasible in NHS wards, but a necessary context for success is ‘site readiness.’

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          Most cited references 19

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          Implementation, context and complexity

          Background Context is a problem in research on health behaviour change, knowledge translation, practice implementation and health improvement. This is because many intervention and evaluation designs seek to eliminate contextual confounders, when these represent the normal conditions into which interventions must be integrated if they are to be workable in practice. Discussion We present an ecological model of the ways that participants in implementation and health improvement processes interact with contexts. The paper addresses the problem of context as it affects processes of implementation, scaling up and diffusion of interventions. We extend our earlier work to develop Normalisation Process Theory and show how these processes involve interactions between mechanisms of resource mobilisation, collective action and negotiations with context. These mechanisms are adaptive. They contribute to self-organisation in complex adaptive systems. Conclusion Implementation includes the translational efforts that take healthcare interventions beyond the closed systems of evaluation studies into the open systems of ‘real world’ contexts. The outcome of these processes depends on interactions and negotiations between their participants and contexts. In these negotiations, the plasticity of intervention components, the degree of participants’ discretion over resource mobilisation and actors’ contributions, and the elasticity of contexts, all play important parts. Understanding these processes in terms of feedback loops, adaptive mechanisms and the practical compromises that stem from them enables us to see the mechanisms specified by NPT as core elements of self-organisation in complex systems.
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            The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change

            Background Despite growth in implementation research, limited scientific attention has focused on understanding and improving sustainability of health interventions. Models of sustainability have been evolving to reflect challenges in the fit between intervention and context. Discussion We examine the development of concepts of sustainability, and respond to two frequent assumptions —'voltage drop,’ whereby interventions are expected to yield lower benefits as they move from efficacy to effectiveness to implementation and sustainability, and 'program drift,’ whereby deviation from manualized protocols is assumed to decrease benefit. We posit that these assumptions limit opportunities to improve care, and instead argue for understanding the changing context of healthcare to continuously refine and improve interventions as they are sustained. Sustainability has evolved from being considered as the endgame of a translational research process to a suggested 'adaptation phase’ that integrates and institutionalizes interventions within local organizational and cultural contexts. These recent approaches locate sustainability in the implementation phase of knowledge transfer, but still do not address intervention improvement as a central theme. We propose a Dynamic Sustainability Framework that involves: continued learning and problem solving, ongoing adaptation of interventions with a primary focus on fit between interventions and multi-level contexts, and expectations for ongoing improvement as opposed to diminishing outcomes over time. Summary A Dynamic Sustainability Framework provides a foundation for research, policy and practice that supports development and testing of falsifiable hypotheses and continued learning to advance the implementation, transportability and impact of health services research.
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              MODELS OF GERIATRICS PRACTICE; The Hospital Elder Life Program: A Model of Care to Prevent Cognitive and Functional Decline in Older Hospitalized Patients

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                Author and article information

                Contributors
                m.godfrey@leeds.ac.uk
                John.green@bthft.nhs.uk
                jane.smith@bthft.nhs.uk
                f.cheater@uea.ac.uk
                AgingBrainCenter@hsl.harvard.edu
                keithhurst.research@yahoo.co.uk
                m.godfrey@leeds.ac.uk
                Journal
                BMC Geriatr
                BMC Geriatr
                BMC Geriatrics
                BioMed Central (London )
                1471-2318
                31 December 2019
                31 December 2019
                2020
                : 20
                Affiliations
                [1 ]ISNI 0000 0004 0379 5398, GRID grid.418449.4, Academic Unit of Elderly Care and Rehabilitation, , Bradford Teaching Hospitals NHS Foundation Trust, ; Bradford, West Yorkshire UK
                [2 ]ISNI 0000 0004 1936 8403, GRID grid.9909.9, Leeds Institute of Health Sciences, , University of Leeds, ; Leeds, West Yorkshire UK
                [3 ]ISNI 0000 0001 1092 7967, GRID grid.8273.e, School of Health Sciences, , University of East Anglia, ; Norwich, UK
                [4 ]ISNI 000000041936754X, GRID grid.38142.3c, Beth Israel Deaconess Medical Center, , Harvard Medical School, ; Boston, MA USA
                [5 ]ISNI 000000041936754X, GRID grid.38142.3c, Aging Brain Center, , Marcus Institute for Aging Research, Hebrew SeniorLife, ; Boston, MA USA
                [6 ]Independent Researcher, Kings Lynn, Norfolk Island
                Article
                1374
                10.1186/s12877-019-1374-x
                6938603
                31892317
                1130a154-a13a-435c-8fda-55538a5422d7
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100007602, Programme Grants for Applied Research;
                Award ID: PG-0108-10037
                Award Recipient :
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2020

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