Getting evidence into practice: the role and function of facilitation
Aim of paper. This paper presents the findings of a concept analysis of facilitation in relation to successful implementation of ...evidence into practice.
Background. In 1998, we presented a conceptual framework that represented the interplay and interdependence of the many factors influencing the uptake of evidence into practice. One of the three elements of the framework was facilitation, alongside the nature of evidence and context. It was proposed that facilitators had a key role in helping individuals and teams understand what they needed to change and how they needed to change it. As part of the on‐going development and refinement of the framework, the elements within it have undergone a concept analysis in order to provide theoretical and conceptual clarity.
Methods. The concept analysis approach was used as a framework to review critically the research literature and seminal texts in order to establish the conceptual clarity and maturity of facilitation in relation to its role in the implementation of evidence‐based practice.
Findings. The concept of facilitation is partially developed and in need of delineation and comparison. Here, the purpose, role and skills and attributes of facilitators are explored in order to try and make distinctions between this role and other change agent roles such as educational outreach workers, academic detailers and opinion leaders.
Conclusions. We propose that facilitation can be represented as a set of continua, with the purpose of facilitation ranging from a discrete task‐focused activity to a more holistic process of enabling individuals, teams and organizations to change. A number of defining characteristics of facilitation are proposed. However, further research to clarify and evaluate different models of facilitation is required.
Primary biliary cirrhosis (PBC) is a classical autoimmune liver disease for which effective immunomodulatory therapy is lacking. Here we perform meta-analyses of discovery data sets from genome-wide ...association studies of European subjects (n=2,764 cases and 10,475 controls) followed by validation genotyping in an independent cohort (n=3,716 cases and 4,261 controls). We discover and validate six previously unknown risk loci for PBC (Pcombined<5 × 10(-8)) and used pathway analysis to identify JAK-STAT/IL12/IL27 signalling and cytokine-cytokine pathways, for which relevant therapies exist.
Treatment guidelines recommend a stepwise approach to primary biliary cholangitis: all patients begin treatment with ursodeoxycholic acid (UDCA) monotherapy and those with an inadequate biochemical ...response after 12 months are subsequently considered for second-line therapies. However, as a result, patients at the highest risk can wait the longest for effective treatment. We determined whether UDCA response can be accurately predicted using pretreatment clinical parameters.
We did logistic regression analysis of pretreatment variables in a discovery cohort of patients in the UK with primary biliary cholangitis to derive the best-fitting model of UDCA response, defined as alkaline phosphatase less than 1·67 times the upper limit of normal (ULN), measured after 12 months of treatment with UDCA. We validated the model in an external cohort of patients with primary biliary cholangitis and treated with UDCA in Italy. Additionally, we assessed correlations between model predictions and key histological features, such as biliary injury and fibrosis, on liver biopsy samples.
2703 participants diagnosed with primary biliary cholangitis between Jan 1, 1998, and May 31, 2015, were included in the UK-PBC cohort for derivation of the model. The following pretreatment parameters were associated with lower probability of UDCA response: higher alkaline phosphatase concentration (p<0·0001), higher total bilirubin concentration (p=0·0003), lower aminotransferase concentration (p=0·0012), younger age (p<0·0001), longer interval from diagnosis to the start of UDCA treatment (treatment time lag, p<0·0001), and worsening of alkaline phosphatase concentration from diagnosis (p<0·0001). Based on these variables, we derived a predictive score of UDCA response. In the external validation cohort, 460 patients diagnosed with primary biliary cholangitis were treated with UDCA, with follow-up data until May 31, 2016. In this validation cohort, the area under the receiver operating characteristic curve for the score was 0·83 (95% CI 0·79-0·87). In 20 liver biopsy samples from patients with primary biliary cholangitis, the UDCA response score was associated with ductular reaction (r=-0·556, p=0·0130) and intermediate hepatocytes (probability of response was 0·90 if intermediate hepatocytes were absent vs 0·51 if present).
We have derived and externally validated a model based on pretreatment variables that accurately predicts UDCA response. Association with histological features provides face validity. This model provides a basis to explore alternative approaches to treatment stratification in patients with primary biliary cholangitis.
UK Medical Research Council and University of Milan-Bicocca.
The Vascular Society of Great Britain and Ireland agrees that we should provide seven day services to patients, 1 if services are adequately resourced and the same facilities offered to all, whether ...weekday or weekend. All of this will cost money, and although we favour the concept of seven day working, we do not believe that today's NHS is sufficiently resourced to deliver safe and effective care at weekends and during the week. ...sufficient resources are identified, we believe that seven day working would result in serious patient safety issues and further "bad press" for the already stretched NHS.
This article outlines the findings from three RCN discussion groups, which aimed to gain an understanding of how nurses were responding to clinical governance and to what extent they were involved in ...its implementation. The article focuses mainly on the third round with clinical nursing staff, senior managers and clinical governance facilitators. Three key issues were reported by nurses taking part in all three rounds of discussion groups. First, there is the need to raise awareness among frontline clinical staff to ensure that clinical governance becomes recognised as an integral part of their clinical workload rather than being seen as an optional extra. The second issue is the need to change organisational culture to make it more receptive to clinical governance. Third is the requirement to establish greater levels of partnerships between clinicians and managers, patients and professionals, and professional groups. However, the authors caution that the organisational cultural change necessary for the successful implementation of clinical governance is not as straightforward as the literature appears to suggest, and argue that this remains a key challenge for organisational leaders, managers and clinical staff.
This article reports on a study exploring the process of implementing nationally developed standards for the nutritional care of older adults. In particular, the study focused on issues which enabled ...or hindered the effective implementation of the standards. A multisite case study design was used. The intervention involved a two-day workshop on facilitated teamwork and implementation strategies. The standards were implemented over a six-month period and a number of semi-structured interviews were conducted in each of the homes throughout this period. Pre- and post-audit data of nutritional care were collected in each of the homes to ascertain the extent to which care had changed. The standards were used effectively as a basis for making significant changes to the way staff provided nutritional care. The research highlighted the importance of using a strategic and well planned approach which addresses four important factors: ensuring the topic area is a priority; using a teamwork approach; identifying a facilitator; and providing necessary educational opportunities.
Child protection: reflection on practice Paeglis, Carol; Loftus-Hills, Alison
RCM midwives : the official journal of the Royal College of Midwives
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Journal Article
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