Adrienne Lewis1, Gill Harvey2, Michelle Hogan3, Alison Kitson4. 1. South Australian Dental Service, GPO Box 864, Adelaide, SA, 5000, Australia; Adelaide Nursing School, Adelaide Health & Medical Sciences Building, The University of Adelaide, SA, 5005, Australia. Electronic address: adrienne.lewis@sa.gov.au. 2. Adelaide Nursing School, Adelaide Health & Medical Sciences Building, The University of Adelaide, SA, 5005, Australia. Electronic address: gillian.harvey@adelaide.edu.au. 3. Helping Hand Inc, 34 Molesworth St, North Adelaide, SA, 5006, Australia. Electronic address: mehogan@helpinghand.org.au. 4. College of Nursing and Health Sciences, Flinders University, Sturt Campus, Sturt Road, Bedford Park, SA, 5042, Australia. Electronic address: alison.kitson@flinders.edu.au.
Abstract
BACKGROUND: An intervention 'Better Oral Health in Home Care' was introduced (2012-2014) to improve the oral health of older people receiving community aged care services. Implementation of the intervention was theoretically framed by the Promoting Action on Research Implementation in Health Services framework. Process outcomes demonstrated significant improvements in older people's oral health. OBJECTIVE: To evaluate the extent to which the intervention has been embedded and sustained into routine community aged care practice 3 years after the initial implementation project. DESIGN: A Realist Evaluation applying Normalisation Process Theory within a single case study setting. SETTING: Community aged care (home care) provider in South Australia, Australia. PARTICIPANTS: Purposeful sampling was undertaken. Twelve staff members were recruited from corporate, management and direct care positions. Two consumers representing high and low care recipients also participated. METHODS: Qualitative methods were applied in two subcases, reflecting different contextual settings. Data were collected via semi-structured interviews and analysed deductively by applying the Normalisation Process Theory core constructs (with the recommended phases of the Realist Evaluation cycle). Retrospective and prospective analytic methods investigated how the intervention has been operationalised by comparing two timeframes: Time 1 (Implementation June 2012-December 2014) and Time 2 (Post-implementation July 2017-July 2018). RESULTS: At Time 1, the initial program theory proposed that multi-level facilitation contributed to a favourable context that triggered positive mechanisms supportive of building organisational and workforce oral healthcare capacity. At Time 2, an alternative program theory of how the intervention has unfolded in practice described a changed context following the withdrawal of the project facilitation processes with the triggering of alternative mechanisms that have made it difficult for staff to embed sustainable practice. CONCLUSION: Findings concur with the literature that successful implementation outcomes do not necessarily guarantee sustainability. The study has provided a deeper explanation of how contextual characteristics have contributed to the conceptualisation of oral healthcare as a low priority, basic work-ready personal care task and how this, in turn, hindered the embedding of sustainable oral healthcare into routine community aged care practice. This understanding can be used to better inform the development of strategies, such as multi-level facilitation, needed to navigate contextual barriers so that sustainable practice can be achieved.
BACKGROUND: An intervention 'Better Oral Health in Home Care' was introduced (2012-2014) to improve the oral health of older people receiving community aged care services. Implementation of the intervention was theoretically framed by the Promoting Action on Research Implementation in Health Services framework. Process outcomes demonstrated significant improvements in older people's oral health. OBJECTIVE: To evaluate the extent to which the intervention has been embedded and sustained into routine community aged care practice 3 years after the initial implementation project. DESIGN: A Realist Evaluation applying Normalisation Process Theory within a single case study setting. SETTING: Community aged care (home care) provider in South Australia, Australia. PARTICIPANTS: Purposeful sampling was undertaken. Twelve staff members were recruited from corporate, management and direct care positions. Two consumers representing high and low care recipients also participated. METHODS: Qualitative methods were applied in two subcases, reflecting different contextual settings. Data were collected via semi-structured interviews and analysed deductively by applying the Normalisation Process Theory core constructs (with the recommended phases of the Realist Evaluation cycle). Retrospective and prospective analytic methods investigated how the intervention has been operationalised by comparing two timeframes: Time 1 (Implementation June 2012-December 2014) and Time 2 (Post-implementation July 2017-July 2018). RESULTS: At Time 1, the initial program theory proposed that multi-level facilitation contributed to a favourable context that triggered positive mechanisms supportive of building organisational and workforce oral healthcare capacity. At Time 2, an alternative program theory of how the intervention has unfolded in practice described a changed context following the withdrawal of the project facilitation processes with the triggering of alternative mechanisms that have made it difficult for staff to embed sustainable practice. CONCLUSION: Findings concur with the literature that successful implementation outcomes do not necessarily guarantee sustainability. The study has provided a deeper explanation of how contextual characteristics have contributed to the conceptualisation of oral healthcare as a low priority, basic work-ready personal care task and how this, in turn, hindered the embedding of sustainable oral healthcare into routine community aged care practice. This understanding can be used to better inform the development of strategies, such as multi-level facilitation, needed to navigate contextual barriers so that sustainable practice can be achieved.
Keywords:
Care workers; Community aged care; Home care; Normalisation process theory; Older people; Oral healthcare; Realist evaluation; Sustainability
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