The Context Assessment Index CAI Brendan Mc Cormack

The ‘Context Assessment Index (CAI) • • • Brendan Mc. Cormack, Professor of Nursing Research, Institute of Nursing Research, University of Ulster, NI (PI) Geraldine Mc. Carthy, Professor/Head of School of Nursing, University College Cork, Ro. I (PI) Jayne Wright, Research Associate, Institute of Nursing Research, University of Ulster Alice Coffey, Research Associate, School of Nursing, University College Cork, Ro. I Paul Slater, Research Associate, Institute of Nursing Research, University of Ulster Project supported by a ‘cross-border’ grant from the NI DHSSPS R&D Office and the Ro. I Health Executive HRB

Background • Project developed to understand the contextual factors that prevent the use of evidence underpinning incontinence management and continence promotion in services for older people. • Development of the tool indicated that it had relevance to other ‘issues’ other than continence and so became the CONTEXT ASSESSMENT INDEX (CAI)

Methodology (1) PHASE 1: In-depth case study (2 sites comprising 7 clinical units): – Individual audit of 220 case records using the Royal College of Physicians (London) audit tool – Facility audit using the Royal College of Physicians (London) audit tool – Knowledge and skills assessment with all staff in the two case study sites (Irwin, 1998) – Observation of practice (32 hours): using Manley’s (2004) ‘indicators of an effective workplace culture’ and ‘Essence of Care Benchmark [continence] (Do. H 2001) – Nurse Leadership: using NWI-R (Aiken & Patrician 2000 adapted by Slater & Mc. Cormack 2005) • Audit data analysed using SPSS and all data mapped onto a matrix developed from the PARi. HS Framework and Manley’s ‘effective workplace culture’ indicators • Focus groups (multidisciplinary) to discuss themes • Discussion of themes and identification of questionnaire items by project team

Methodology (2) PHASE 2: REFINEMENT AND TESTING OF THE CAI • Pre-pilot with convenience sample of continence link nurses – refinement of items (wording and number) • Pilot with 15 practice development nurses and continence nurse specialists from across the UK – refinement of items (wording and number) • Validity testing: Distribution of the CAI (82 item instrument) to 500 nurses drawn from a sample of nurses in all rehabilitation units in Ireland (NI & Ro. I) – refinement of instrument. • Reliability testing: test-retest approach with nurse leaders in 50 rehabilitation units drawn from a sample of rehabilitation units in Ireland (NI & Ro. I) –refinement of instrument

Methodology (3) PHASE 2: REFINEMENT AND TESTING OF THE CAI • Validity testing: – – – 54% response rate Refine, reduce and isolate items Exploratory factor analysis • • Items that were retained Items that load onto >1 factor (retain) Items that were weak across >1 factor (reject) Items that were weak on 1 factor only (Theoretical analysis and keep or reject) • Show items that: – – – Strongly fit onto existing PARIHS constructs Weakly fit onto existing PARIHS constructs ‘Novel’ items in the context of the PARIHS framework • Outcome – 37 item instrument

Using the Context Assessment Index (CAI) in practice: facilitating consciousness raising for practice development Brendan Mc. Cormack, Professor of Nursing Research, Institute of Nursing Research, University of Ulster, NI (PI) Jayne Wright, Research Associate, Institute of Nursing Research, University of Ulster

AIMS • implement the (CAI) in designated clinical areas • evaluate the CAI's effectiveness as a diagnostic tool for aiding practitioners understanding of the contextual factors to develop person centred continence care and thus, improve the continence care that older people receive.

Methodology • Emancipatory Practice Development – – – Pre and post use of CAI Observations of practice Focus groups Site profiles External facilitator engaging in: • !: 1 supported reflective practice with clinical leaders • Action learning (staff groups) • Action planning

Outcomes 1 • The CAI was effective in aiding practitioner understanding of the contextual factors enhancing or hindering practice context leading to changes in practice. • The CAI can be used as a diagnostic tool to determine an area’s readiness for change. However, a high score does not necessarily indicate that the area is ready for change or that the context is ‘strong’. Alongside the context score, information is needed such as; whether the area has engaged in any practice development activity and how care is evaluated. This then gives a better idea of whether the score reflects the context. An area that scores themselves as having a low context might be more ready for change (i. e. they have insight into practice) than a site that achieves high scores.

Outcomes 2 • The CAI is more effective when applied in settings where practitioners have engaged in some practice development activities and have raised consciousness of the strengths and weaknesses of existing practice • Each area had varied leadership. Those areas that engaged with and achieved the most from the study had leadership that could be described as transformational. • The process alone of completing the CAI aided reflection on practice context. • A facilitator was essential for the practitioners to engage with the CAI, in understanding context and in making practice changes. • The CAI captured the internal contextual factors but it was difficult to separate factors that were internal to each site from the external factors affecting practice context.

Further Work • • • Further test the usability of the CAI in practice through a multi site large scale study. Test the CAI in various settings other than older peoples rehabilitation Review the context aspect of the PARIHS framework to reflect external factors affecting practice context and consider removing the sub-element of context and merging the characteristics into the other 3 elements.