title: A qualitative study of a primary-care based intervention to improve the management of patients with heart failure: the dynamic relationship between facilitation and context.
abstract: BACKGROUND
  There is currently a growing emphasis in primary care on upscaling the provision of evidence-based services for specific conditions, such as heart failure (HF), which have traditionally been seen as part of a specialist's domain. While contextual challenges associated with improvement in primary care have been documented previously, we still know relatively little about how the intentional, theory-informed facilitation of evidence-based change is shaped by contextual factors within this healthcare setting. Hence, a qualitative study was conducted to address the question: How is the process of facilitating evidence-based practice affected by the context of primary care?
  
  
  METHODS
  Data collection took place across general practices in northwest England as part of a process evaluation of the Greater Manchester HF Investigation Tool (GM-HFIT) - a programme of work aiming to improve the management of HF in primary care. Semi-structured interviews, with purposefully selected GM-HFIT team members (n = 9) and primary care practitioners (n = 7), were supplemented by observational data and a three-month diary reflecting on facilitation activities. Framework analysis was used to manage and interpret data.
  
  
  RESULTS
  We describe a complex and dynamic interplay between facilitation and context, focusing on three major themes: (1) Addressing macro and micro agendas; (2) Forming a facilitative unit; (3) Maintaining momentum. We show that HF specialist nurses (HFSNs) have a high level of professional credibility, which allows them to play a key role in making recommendations to practices for improving patient care. At the same time, we argue that contextual factors, such as top-level endorsement, the necessity to comply with a performance measurement system, and the varying involvement of practice nurses produce tensions that can have both an enabling and constraining effect on the process of facilitation.
  
  
  CONCLUSIONS
  When facilitating the transfer of evidence, context is an important aspect to consider at a macro and micro level; a complex interplay can exist between these levels, which may constrain or enable efforts to amend practice. Those involved in facilitating change within primary care have to manage tensions arising from the interplay of these different contextual forces to minimise their impact on efforts to alter practice based on best evidence.
authors.affiliation: Royal College of Nursing Research Institute, University of Warwick, Coventry, UK. sjftierney@yahoo.co.uk.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Tierney
authors.forename: Roman
authors.initials: R
authors.lastname: Kislov
authors.forename: Christi
authors.initials: C
authors.lastname: Deaton
mesh_terms: D001291:Attitude of Health Personnel; D064646:Cardiovascular Nursing; D004059:Diffusion of Innovation; D019468:Disease Management; D019317:Evidence-Based Medicine / Q000379:methods* / Q000458:organization & administration; D058006:General Practice; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D009936:Organizational Innovation; D011320:Primary Health Care / Q000379:methods* / Q000458:organization & administration; D017064:Process Assessment, Health Care; D036301:Qualitative Research; D058996:Quality Improvement