Barriers and Facilitators to Screening for Cognitive Impairment in Australian Rural Health Services: A Pilot Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Evaluation Framework
- Innovation, considers the characteristics of knowledge and how these affect its practical application;
- Recipients, considers the impact of individuals or groups of individuals in supporting or resisting innovation;
- Inner and outer contexts, considers the resources, culture, leadership, policy and capacity for innovation at both the local and wider organisational levels.
2.2. Study Design and Setting
Participant Recruitment and Data Collection
2.3. Data Analysis
3. Results
3.1. Themes Identified
3.1.1. Legislation
‘It [screening] is now a requirement that we’re mandated to do it.’… FG1.
3.1.2. ‘Staff Buy-In’
‘It’s been like a group involvement… we come to the meetings …we’ve sort of all been gradually introduced to it.’… positive point where we think that it’s right.’… FG1.
‘The education was really more about bringing people on the journey, not just introducing another piece of paper, which would have just—we would have had a mutiny.’… ‘That’s what I encourage… is that this is not just another bit of paper.’… FG1.
‘The other thing is that so what factor, so what can we do afterwards? Like if the results show a cognitive impact… there’s a lack of services to actually put something into place [for that] person.’… FG2.
‘It’s not something additional that you’re doing because you’re already doing that.’… FG1.
‘To have something that you can actually tick and say, yes, I’ve done this, yes, I’ve covered that, I’ve excluded this, I’ve included—thought about that.’…… FG1.
‘There isn’t often a lot of time and we need to get that value out of whatever tool we’re going to use’.… ‘It’s a never-ending paper trail again.’… FG1.
3.1.3. Ancillary Services and Support
‘If we do identify that deficit what do we do with it and who do—we don’t have access to a neuropsych. Trying to get access to an OT or psychologist is very difficult.’… I1.
‘We have access to a lot of good support systems… to the supports we need for people, and we also have very good relationships with. So in some ways I think being smaller is easier for everyone to know what’s happening.’… I2.
3.1.4. Tool Availability
‘The Australian hospital guides and in that—the standards, it gives you a list of tools that are the best practice tools.’… FG1.
‘One of the tests, to be honest, we’re all worried about failing ourselves.’… FG1.
‘There can also be concern that clients may memorise the test, like for example the mini-mental state examination that’s run often in hospitals.’… FG2.
3.1.5. Reliance on Clinical Experience
‘Screening is generally in-home and observation of people functioning in their own environment. Then if it flagged … they would go on and use a more formalised [tool].’… I3.
‘I’ll just make a point that in our cohort of people with mental illness and drug and alcohol problems, 65 is probably a little bit too old. I’d be looking at over 55 for when you’re wanting to screen for those sorts of things.’… I1.
3.1.6. Training and Proficiency
‘And we did them [screening] on each other and that was really helpful, actually having that practice of saying the script.’… ‘Doctors came back and said just do a mini-mental, and I’m like no, I don’t want to do a mini-mental for these reasons. I had the confidence to be able to explain.’… FG2.
‘My degree specifically I probably had two to three weeks max on the cognitive screening.’… FG2.
3.1.7. Patient Experience as a Motivator
‘They found the patient didn’t have delirium but it was actually a cognitive impairment that they’d had previous to coming in.’…‘There’s been a mentality of, quick, let’s get them back to their own environment because that’s—they’re going to quickly improve in their own environment when it potentially might not be the case as well.’… FG1.
‘A hesitancy to ask them the question if you do know them and they answer incorrectly … It could be sort of embarrassing for them.’… FG1.
‘Just a lot of clients are really worried that you’re going to take off their driver’s licence…’… FG2.
3.1.8. Familiarity
‘With the smaller hospital, maybe something that could come up is that we know a lot of our patients… we assume that they’re going to be negative or positive for the cognitive impairment.’… FG1.
3.2. i-PARIHS Framework for Successful Implementation
- Within the innovation construct—relative advantage of building on existing process and making current practice easier; clarity from shared purpose and understanding; compatibility with/of existing practices and available tools; existing evidence bases as underlying knowledge sources; careful consideration of existing tools and relevance to the context to enhance usability; and motivation through identifying observable patient benefits.
- Within the recipient construct—a collaborative approach in which all experiences and contributions are valued to achieve staff buy-in and therefore collaboration and teamwork; providing sufficient time as well as resources and support through training opportunities; looking to existing networks for support and capacity in light of limited specialist availability; addressing skills and knowledge through training; and leveraging clinical experience to give context to screening protocols.
- Within the context construct—creating a supportive learning environment (local and organizational level) and fostering training and sufficiency through gradual change and the provision of training (in the workforce and tertiary education); advocating for legislation to address policy drivers, mandates and regulatory frameworks as drivers of screening adoption; and leveraging organisational supports and relationships to overcome specialist shortages as barriers to addressing the results of screening.
4. Discussion
4.1. Factors Consistent with Previous Studies in Rural and/or Urban Settings
4.2. Factors Exacerbated in the Current Rural Setting
4.3. Factors Salient in the Current Rural Setting
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Innovation | Recipients | Context |
---|---|---|
Underlying knowledge sources Clarity Degree of fit with existing practice and values (compatibility or contestability) Usability Relative advantage Trialability Observable results | Motivation Values and beliefs Goals Skills and knowledge Time, resources, support Local opinion leaders Collaboration and teamwork Existing networks Power and authority Presence of boundaries | Local level: Formal and informal leadership support Culture Past experience of innovation and change Mechanisms for embedding change Evaluation and feedback processes Learning environment Organisational level: Organisational priorities Senior leadership and management support Culture Structure and systems History of innovation and change Absorptive capacity Learning networks External health system level: Policy drivers and priorities Incentives and mandates Regulatory frameworks Environmental (in)stability Inter-organisational networks and relationships |
Focus Group /Interview | Institution Represented | Number of Participants | Disciplines/Backgrounds of Participants |
---|---|---|---|
Focus Group 1 (FG1) | Tertiary Care | 7 | Nursing, Gerontology |
Focus Group 2 (FG2) | Primary/community care | 9 | Allied health (Occupational Therapy, Physiotherapy, Exercise Physiology) |
Interview 1 (I1) | Primary/community care | 3 | Allied health, Nursing |
Interview 2 (I2) | Primary/community care | 2 | Allied health (Occupational Therapy), Nursing |
Interview 3 (I3) | Primary/community care | 1 | Allied health (occupational therapy) |
Theme | Sub-Theme | i-PARIHS Domain |
---|---|---|
Legislation | Policy/guidelines/legislation * | Context External health system level - Policy drivers and priorities, incentives and mandates, regulatory frameworks |
Staff-buy in | Nothing new (leveraging and validating existing process) | Innovation—Compatibility (degree of fit within existing practice) Innovation—Relative advantage and compatibility |
Collaborative journey | Recipients—collaboration and teamwork Context Local level—learning environment Organisational level—learning networks | |
Meaning and purpose | Innovation—clarity & usability | |
Systematic approach to enhance practice & make it easier | Innovation—relative advantage | |
Time & workloads as barriers | Recipients—time, resources and support | |
Ancillary services and support | Limited/restricted access to specialists for ‘the next step’ | Context—External health system—environmental instability Context—external health system—interorganisational networks and relationships Recipients—existing networks |
Interorganisational roles and relationships | Context—external health system—inter organisational networks and relationships | |
Tool availability | Evidence base of standardised tested tools | Innovation—underlying knowledge sources |
Context appropriate | Innovation—compatibility and usability | |
Validity of tool—relevance of the questions and the underpinning domains tapped into | Innovation—compatibility and usability | |
Reliance on clinical experience | Over-reliance/overconfidence potentially limiting | Recipients—values and beliefs |
Clinical experience to enhance/complement screening | Recipients—skills and knowledge | |
Training and proficiency | Training = experience = knowledge and confidence | Recipients—time resources and support, and skills and knowledge Context Local level—learning environment Organisational level—learning networks |
Lack of training or proficiency | Context—Local level—learning environment Recipients—skills and knowledge | |
Patient experience as a motivator | Observable & tangible benefits | Recipient—motivation |
Patient (dis)comfort & fear of negative outcomes | Recipient—motivation | |
Spectrum of familiarity and implications for screening | Context—External health system level |
Barrier | Facilitator |
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MacDermott, S.; McKechnie, R.; LoGiudice, D.; Morgan, D.; Blackberry, I. Barriers and Facilitators to Screening for Cognitive Impairment in Australian Rural Health Services: A Pilot Study. Geriatrics 2022, 7, 35. https://doi.org/10.3390/geriatrics7020035
MacDermott S, McKechnie R, LoGiudice D, Morgan D, Blackberry I. Barriers and Facilitators to Screening for Cognitive Impairment in Australian Rural Health Services: A Pilot Study. Geriatrics. 2022; 7(2):35. https://doi.org/10.3390/geriatrics7020035
Chicago/Turabian StyleMacDermott, Sean, Rebecca McKechnie, Dina LoGiudice, Debra Morgan, and Irene Blackberry. 2022. "Barriers and Facilitators to Screening for Cognitive Impairment in Australian Rural Health Services: A Pilot Study" Geriatrics 7, no. 2: 35. https://doi.org/10.3390/geriatrics7020035
APA StyleMacDermott, S., McKechnie, R., LoGiudice, D., Morgan, D., & Blackberry, I. (2022). Barriers and Facilitators to Screening for Cognitive Impairment in Australian Rural Health Services: A Pilot Study. Geriatrics, 7(2), 35. https://doi.org/10.3390/geriatrics7020035