title: Promoting continence in nursing homes in four European countries: the use of PACES as a mechanism for improving the uptake of evidence-based recommendations.
abstract: BACKGROUND
  Multi-faceted approaches are generally recognised as the most effective way to support the implementation of evidence into practice. Audit and feedback often constitute one element of a multi-faceted implementation package, alongside other strategies, such as interactive education and facilitated support mechanisms. This paper describes a multi-faceted implementation strategy that used the Joanna Briggs Institute Practical Application of Clinical Evidence System (PACES) as an online audit tool to support facilitators working to introduce evidence-based continence recommendations in nursing homes in four different European countries.
  
  
  OBJECTIVE
  The paper describes the experience of using PACES with an international group of nursing home facilitators. In particular, the objectives of the paper are: to describe the process of introducing PACES to internal facilitators in eight nursing homes; to discuss the progress made during a 12-month period of collecting and analysing audit data using PACES; to summarise the collective experience of using PACES, including reflections on its strengths and limitations.
  
  
  METHODS
  Descriptive data were collected during the 12-month period of working with PACES in the eight nursing home sites. These data included digital and written notes taken at an initial 3-day introductory programme, at monthly teleconferences held between the external and internal facilitators and at a final 2-day meeting. Qualitative analysis of the data was undertaken on an ongoing basis throughout the implementation period, which enabled formative evaluation of PACES. A final summative evaluation of the experience of using PACES was undertaken as part of the closing project meeting in June 2011.
  
  
  RESULTS
  The nursing home facilitators took longer than anticipated to introduce PACES and it was only after 9-10 months that they became confident and comfortable using the system. This was due to a combination of factors, including a lack of audit knowledge and skills, limited IT access and skills, language difficulties and problems with the PACES system itself. The initial plan of undertaking a full baseline audit followed by focused action cycles had to be revised to allow a more staged, smaller-scale approach to implementation and audit. This involved simplifying the audit process and removing steps such as the calculation of population size estimates. As a result, an accurate baseline measure, prior to introducing changes to continence care, was not achieved. However, by the end of the 12 months, the majority of facilitators had undertaken a full audit and reported value in the process. In particular, they benefited from comparing audit data across sites to share learning and best practice.
  
  
  CONCLUSIONS
  Working with PACES as part of a facilitated programme to support the implementation of evidence-based continence recommendations in nursing homes in four European countries has been a valuable learning experience, although not without its challenges. The findings highlight the importance of thorough training and support for first time users of PACES and the need to make the audit process as simple as possible in the initial stages.
authors.affiliation: Health Management Group, Manchester Business School, Manchester, UK. gill.harvey@mbs.ac.uk
authors.forename: Gill
authors.initials: G
authors.lastname: Harvey
authors.forename: Alison
authors.initials: A
authors.lastname: Kitson
authors.forename: Zachary
authors.initials: Z
authors.lastname: Munn
mesh_terms: D004059:Diffusion of Innovation; D005060:Europe; D055317:Evidence-Based Practice; D006801:Humans; D009735:Nursing Homes; D058996:Quality Improvement; D014549:Urinary Incontinence / Q000451:nursing