Context Assessment Index

The Context Assessment Index contains at least 37 items, which will provide the researcher with the requisite means to evaluate and gain insight into whether the organizational culture is effective in improving productivity and handoff of patients.  The first theme explored is the culture of the entity, which is defined by scholars to be the values, beliefs, or even the modus operandi of an entity (Johnson, 2008). The culture is applicable in the organizational, team as well as individual levels. Cummings, Estabrooks, Midodzi, Wallin & Hayduk (2007) show that the culture of a practice setting has to be understood prior to the development and implementation of leadership initiatives.

The second theme is leadership, which determines the level of support and willingness of the top brass to accept change. Leaders are required to inspire the employee towards a shared vision of the future with communication and trust, playing a noteworthy role in improving the implementation process (Cummings, Estabrooks, Midodzi, Wallin, & Hayduk, 2007). The final theme is an evaluation which explores the cost-efficacy of the current strategies and how they can be improved. Effective cultures utilize evidence gathered through a myriad of sources to make decisions on the effectiveness of individual and organizational processes (Cummings, Estabrooks, Midodzi, Wallin, & Hayduk, 2007; Johnson, 2008). The data further operates as a major part of staff appraisal strategies and accountability frameworks  (Cummings, Estabrooks, Midodzi, Wallin, & Hayduk, 2007).

The three themes are assessed and evaluated on a continuum ranging from weak to strong. Johnson(2008) highlights that an effective culture is one that should be receptive to change with the employees improving the values of the items on the continuum towards being strong.

The CAI was formulated from the foundations laid by the Promoting Action on Research Implementation in Health Services conceptual framework. This framework is momentous for this research as it identifies the numerous issues faced by entities when implementing change. The content and face validity of the CAI was tested through the combination of both quantitative and qualitative method. University of Ulster (2020) highlights that the analysis has to take into account three factors, namely the clarity of the statements in the tool, the layout as well as the clarity of terminology.  The author further adumbrates that the statements need to be clear and unambiguous for easy understanding. Barrel statements should be removed in a bid to improve implementation (University of Ulster, 2020).

Figure 1: CAI Themes

Moving further, the strength of the factor structure of the 37 items was improved through the initial analysis of the items through the use of a principle components scheme. The scheme helped in identifying the select number of factors in the questionnaire, after which they were extracted by checking their Eigenvalues. McCormack, McCarthy, Wright, Slater, & Coffey (2009) argue that the 37 items need to undergo an exploratory factor analysis, which ensures for the emergence of the strongest factor structure from the data.  Maximum likelihood analyses can come in handy in extracting the factor structures (McCormack, McCarthy, Wright, Slater, & Coffey, 2009).

Additionally, McCormack, McCarthy, Wright, Slater, & Coffey (2009) indicate that discreet factor structures can be identified through the use of varimax rotated extraction. The extraction should be based on the findings derived from the cultural analysis of the healthcare entity. Recommendations from McCormack, McCarthy, Wright, Slater, & Coffey (2009)  opine that the homogeneity of the tool should be measured and calculated to determine the levels of internal reliability. In the case that the tool has a Cronbach alpha score of 0.93, then it goes without saying that it has achieved a satisfactory level of internal consistency.

The item scores of every factor evaluated in the research is summed up in order to produce a factor score for every respondent. The end outcome is then divided by the number of items in a bid to produce a mean score on the factor for the items. It is imperative to note that a level of agreement should be identified between the main factors, which will, in turn, signify the efficacy of the tools (McCormack, McCarthy, Wright, Slater, & Coffey, 2009; Hardy, 2011). Deductions from the paper highlight that the total score of the culture theme was set at 81.25%, which came in a close second to the leadership scores at 82.11%. The evaluation scores were at 78.32%, as shown in Appendix B.

Figure 1: Culture Scores

Figure 2: Leadership scores

Figure 3: Evaluation scores

Barriers

The pragmatic definition of a barrier is any circumstance that prevents or undermines the attainment of specific goals and objectives. In the context of the urban healthcare center, the researcher identified at least two barriers that influence the implementation of the standardized patient handoff protocol. The first factor is the staff with specific factors like familiarity, age, attitude, and education being cited as key issues to be addressed.

The staff factor falls under the culture theme wherein the management’s recruitment and retention strategies directly or indirectly influence patient handoff. Take, for instance, the healthcare entity’s workforce is made up of a diverse group of people, although most of them are over the age of 50. The management prefers older employees because of the experience that they bring to the table. On the contrary, the employees are not entirely hands-on with years of tedious work, causing them to make errors during the filing process or even the identification of the surgery room that the patient should be in.

Another instance is shown in the fact that the management is accustomed to hiring people from various backgrounds and racial composition in order to improve diversity in the workforce. This has, in turn, caused issues in communication as most of them are not entirely cognizant of the first language. Addendum to this, most of the communication is marked by a loss in translation, which can ultimately lead to medication errors or delayed treatment (Patterson & Wears, 2010).

The second barrier to the standardized handoff is the hospital environment, which falls under the leadership and culture theme. To begin with, a good number of the employees argue that they do not entirely understand what the organization requires of them when it comes to the provision of care. The resident nurses and other members of the organization who hold minor positions are oft required to follow through what the management tells them to do. This, in turn, causes a rise in dissatisfaction and turnovers. With increased turnovers comes decreased employee levels, which thereby causes delays in patient handoff  (Patterson & Wears, 2010).

The management structure implemented in the organization is criticized for being non-inclusive and authoritarian by nature. New healthcare workers oft find it hard to keep up with the organizational culture as there is no training framework in place  (Patterson & Wears, 2010). Addendum to this, the organization does not ascribe to the non-hierarchical principles required for healthcare entities. This means that the employees do not operate in groups/ teams based on the needs of their current line of work. The increased number of managers in the organization slows down the decision-making process, with the administrative costs rising by the day  (Patterson & Wears, 2010).

Enablers

Conversely, the CAI notes that the firm has a select number of enablers, which will help in the implementation of the standardized protocol. The first enabler is that the staff document all the decisions that are made on the care and management of patients. This factor is important as the employees are offered step by step analyses on how to book and discharge the patients  (Patterson & Wears, 2010). The second enabler is that the care and treatment aspects are all based on evidence of best practice. This follows through the principles of evidence-based practice, whereby the nurses are expected to use their clinical expertise, the best external evidence as well as patient preferences to identify the best course of treatment. This negates the need for the nurses or medical practitioners to wait on the top brass of management to relay decisions or instructions on what needs to be done.

The final enabler is that staff performance is done on the regular, which allows for a reflection on practice as well as the setting of goals. Such performance reviews are important in identifying the employees who lag behind in implementing medical interventions  (Patterson & Wears, 2010). The employee needs are then addressed through relegation to roles that are not arduous or even direct replacement by youthful employees.

Summary

The main reason why the CAI tool was chosen over others is that it can be completed by any healthcare professional who actively or passively works in areas that require patient handoff. The plethora of information collected from diverse employees can come in handy in providing the management with the necessary insight into how they can mitigate the negative impact of slow handoffs (Newhouse, 2010). The second merit is that it expands the level of cohesion in the healthcare entity as the employees are able to air out their views and discuss them even though they are differing. Critical analysis of responses is vital for the management of the issue as the employees will join heads or even compromise their beliefs to address the issue at hand. The tool clearly shows that the organization is ready for a change in terms of culture and leadership framework. The element themes, however, raise concern, although it can be supplemented through improved focus on the first two themes.

References

Cummings, G. G., Estabrooks, C. A., Midodzi, W. K., Wallin, L., & Hayduk, L. (2007). Influence of organizational characteristics and context on research utilization. Nursing Research.

Hardy, J. (2011). Exploring the construct validity of the Context Assessment Index (CAI) using the Rasch model of item response theory with data collected in a Western Australian tertiary hospital.

Johnson, C. (2008). Highlights of the Basic Components of Evidence-Based Practice. Journal of Manipulative and Physiological Therapeutics.

McCormack, B., McCarthy, G., Wright, J., Slater, P., & Coffey, A. (2009). Development and Testing of the Context Assessment Index (CAI). Worldviews on Evidence-Based Nursing.

Newhouse, R. P. (2010). Instruments to Assess Organizational Readiness for Evidence-Based Practice.

Patterson, E. S., & Wears, R. (2010). Patient Handoffs: Standardized and Reliable Measurement Tools Remain Elusive.

University of Ulster. (2020). CONTEXT ASSESSMENT INDEX.