www.ualberta.ca/~kusp The Alberta Context Tool (ACT) Carole A. Estabrooks Professor & Canada Research Chair Janet Squires Doctoral candidate Faculty of Nursing University of Alberta KU09 Wales, UK June 24-26, 2009 k n o w l e d g e i n p r a c t i c e. . . www.ualberta.ca/~kusp ACT overview • 59 items representing 8 modifiable dimensions of context • Currently 3 versions • Adults (acute care) • Pediatrics (acute care) • Long term care 6 groups • • • • • • Healthcare Aides (LTC only) Nurses Allied Physicians Specialists/Educators Managers k n o w l e d g e i n p r a c t i c e. . . www.ualberta.ca/~kusp Initial ACT development 1. Selection of a conceptual framework • • Critical review of literature Promoting Action on Research Implementation in Health Services (PARiHS) framework as initial guide 2. Conceptual refinement • • Addition of concepts to incorporate team’s understanding of other relevant aspects of organizational context Conceptual and operational definitions developed k n o w l e d g e i n p r a c t i c e. . . www.ualberta.ca/~kusp Initial development 3. Survey construction • • Item construction Initially versions for 5 groups in adult acute care (RN/LPN, MD, Allied, Managers, Educators) 4. Feasibility modifications • • Survey administration and debriefing sessions were held with members of the five groups (summer, 2006) Modifications made based on debriefing feedback • • • Question clarity Revision of examples Length/respondent burden 5. Response process validity evidence k n o w l e d g e i n p r a c t i c e. . . Framework PARiHS Framework Research implementation Leadership Adding to context Context Culture Evidence Facilitation Evaluation Individual attributes Kitson, et al., 1998, QSHC Rycroft-Malone et al, 2002 (J Adv Nurs) + • Slack • Interactions • Resources • Social capital • Attitude • PSA • Belief suspension • MBI • SF-8 ACT Framework Leadership Adding to context Context Culture Evaluation • Organizational slack • Formal interactions • Informal interactions • Structural & electronic resources • Social capital Structure of ACT 1. Leadership • 6 items scored on a 5-point Likert like scale • Concepts reflected in items: openness, optimism, self control, em pathic, developing others, conflict management • e.g., The leader calmly handles stressful situations 2. Culture • 6 items scored on a 5-point Likert like scale • Concepts reflected in items: recognition, autonomy, worklife balan ce, development opportunity, focus on service/mission, support • e.g., I receive recognition from others about my work 3. Evaluation • 6 items scored on a 5-point Likert like scale • Concepts reflected in items: data access, informal data review, for mal data review, action planning, performance monitoring, bench marking • e.g., Our team routinely discusses this data informally Structure of ACT 4. Formal Interactions • 5 items scored on a 5-point frequency scale • Concept reflected in items: Interactions with others through engagement in formal organizational (unit) activities • e.g., Team meetings about residents 5. Informal Interactions • 6-9 items scored on a 5-point frequency scale • Concept reflected in items: Interactions with others through engagement in informal organizational (unit) activities • e.g., Other professionals in my discipline 6. Social Capital • 6 items scored on a 5-point Likert like scale • Concepts reflected in items: bonding, bridging, linking • e.g., People in my group share information with others in the group Structure of ACT 7. Structural and Electronic Resources • Structural: 9 items scored on a 5-point frequency scale • Electronic: 3 items scored on a 5-point frequency scale • Concept reflected in items: availability/use of structural and electronic resources • e.g., Policy and procedure manuals 8. Organizational Slack • 9-11 items consisting of 3 sub-scales • Staffing (2-3 items scored on a 5-point Likert like scale assessing availability of adequate staffing resources • Space (3-4 items scored on Likert and frequency scales assessing availability and use of space • Time (4 items scored on a 5-point frequency scale assessing availability and use of time) • e.g., Have time to do something extra for residents www.ualberta.ca/~kusp Validation k n o w l e d g e i n p r a c t i c e. . . The Standards1 approach to validity A unitary approach to validity assessment where empirical results are classified as supporting (or refuting) validity Validity Source Explanation Content To what extent does the content of the items represent the content of the domain? e.g., expert panel, CVI Response Process To what extent do the respondents’ responses fit the intended construct? Do respondents interpret, process, and elaborate upon item content and is this behaviour in accordance with the construct? e.g., revise items from pretest, interview to confirm instrument Internal Structure To what extent do the relationships among the items match the construct as operationally defined and do the data support dimensionality? e.g., factor analysis, item analysis (IRT) Relationships with other Variables What is the nature and extent of the relationships between instrument scores and: - variables it is expected to correlate with or predict - variables it is not expected to correlate with or predict e.g., correlations, regression 1 Standards for Educational and Psychological Testing. AERA; 1999. www.ualberta.ca/~kusp Initial validation (AKUTE1 study) • Acute Care (Adult) setting • 4 teaching hospitals in Alberta • 5 professional provider groups (N=453) • Reliability (alpha) • Range: .65 (formal interactions) to .92 (evaluation) • All but one >.70 • Validity (internal structure evidence) • Factor analysis (PCA with Varimax rotation) 14 factor solution; 67% of the variance ACT core (culture, leadership, evaluation – 31.95% of variance) 1`AKUTE: Estabrooks, Norton, Birdsell, Cummings, Newton. AHFMR funded k n o w l e d g e i n p r a c t i c e. . . www.ualberta.ca/~kusp Second validation study (pilot + wave 1 CIHR Team in Children’s Pain) • Survey revisions made based on pilot findings from four pediatric acute care units in Alberta (response process) • Validation study - acute care (pediatric) setting • 8 pediatric hospitals across Canada • 5 professional provider groups (N=1248) • Validation with Nurses (N=850) • Reliability (alpha) • Range: .60 (formal interactions) to .91 (evaluation) • All >.70 except for formal interactions (.60) and space (.65) k n o w l e d g e i n p r a c t i c e. . . www.ualberta.ca/~kusp Second validation study • Validity (internal structure evidence) • Item assessment • Item-total statistics remained stable • Factor analysis • 14 factor solution; 61% of the variance • ACT core (culture, leadership, evaluation – 27.63%) • Some realignment of items (formal/informal interactions) k n o w l e d g e i n p r a c t i c e. . . www.ualberta.ca/~kusp Second validation study • Validity (relationship with other variables evidence) • Correlation analysis • All ACT dimensions significantly correlated with IRU • Range: r=.052 (OS-staff) to .272 (structural/electronic resources) • Regression Analysis • 7/8 ACT dimensions predict research use (at hospital level) at p<.10 (exception: structural/electronic resources) k n o w l e d g e i n p r a c t i c e. . . www.ualberta.ca/~kusp Additional Validation (CapitalCare studuy) Pilot Study • 91 LPNs and HCAs in 4 long-term care units • Extensive feasibility testing (response process validity evidence) • Reliability: • Alpha > .70 for 7/8 dimensions (formal interactions revised) • Alpha range 0.50 (formal interactions) to 0.96 (evaluation) k n o w l e d g e i n p r a c t i c e. . . www.ualberta.ca/~kusp Ongoing plans The ACT currently under revision • i.e., harmonize across versions , reduce the number of versions Planned validation: • Psychometric assessment in new populations and in settings: Further psychometric assessment: • Item Response Theory (IRT) • Confirmatory Factor Analysis (CFA) Ongoing work re scoring of dimensions Assessment of translated versions (e.g., Swedish, French) k n o w l e d g e i n p r a c t i c e. . . www.ualberta.ca/~kusp k n o w l e d g e i n p r a c t i c e. . .