title: Mechanisms which help explain implementation of evidence-based practice in residential aged care facilities: a grounded theory study.
abstract: BACKGROUND
  The context for the study was a nation-wide programme in Australia to implement evidence-based practice in residential aged care, in nine areas of practice, using a wide range of implementation strategies and involving 108 facilities. The study drew on the experiences of those involved in the programme to answer the question: what mechanisms influence the implementation of evidence-based practice in residential aged care and how do those mechanisms interact?
  
  
  METHODS
  The methodology used grounded theory from a critical realist perspective, informed by a conceptual framework that differentiates between the context, process and content of change. People were purposively sampled and invited to participate in semi-structured interviews, resulting in 44 interviews involving 51 people during 2009 and 2010. Participants had direct experience of implementation in 87 facilities, across nine areas of practice, in diverse locations. Sampling continued until data saturation was reached. The quality of the research was assessed using four criteria for judging trustworthiness: credibility, transferability, dependability and confirmability.
  
  
  RESULTS
  Data analysis resulted in the identification of four mechanisms that accounted for what took place and participants' experiences. The core category that provided the greatest understanding of the data was the mechanism On Common Ground, comprising several constructs that formed a 'common ground' for change to occur. The mechanism Learning by Connecting recognised the ability to connect new knowledge with existing practice and knowledge, and make connections between actions and outcomes. Reconciling Competing Priorities was an ongoing mechanism whereby new practices had to compete with an existing set of constantly shifting priorities. Strategies for reconciling priorities ranged from structured approaches such as care planning to more informal arrangements such as conversations during daily work. The mechanism Exercising Agency bridged the gap between agency and action. It was the human dimension of change, both individually and collectively, that made things happen.
  
  
  CONCLUSIONS
  The findings are consistent with the findings of others, but fit together in a novel way and add to current knowledge about how to improve practices in residential aged care. Each of the four mechanisms is necessary but none are sufficient for implementation to occur.
authors.affiliation: Centre for Health Service Development, Australian Health Services Research Institute, Building 234 (iC Enterprise 1), Innovation Campus, University of Wollongong, NSW 2522, Australia. Electronic address: mmasso@uow.edu.au.
authors.forename: Malcolm
authors.initials: M
authors.lastname: Masso
authors.affiliation: Faculty of Business, University of Wollongong, NSW 2522, Australia. Electronic address: gracemc@uow.edu.au.
authors.forename: Grace
authors.initials: G
authors.lastname: McCarthy
authors.affiliation: School of Nursing, The University of Adelaide, South Australia 5005, Australia. Electronic address: alison.kitson@adelaide.edu.au.
authors.forename: Alison
authors.initials: A
authors.lastname: Kitson
mesh_terms: D055317:Evidence-Based Practice; D006707:Homes for the Aged / Q000458:organization & administration*; D008962:Models, Theoretical
keywords: Aged care; Evidence-based practice; Grounded theory; Implementation science; Nursing homes; Qualitative research