The Alberta Context Tool (ACT)

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The Alberta Context Tool (ACT)
Carole A. Estabrooks Professor Canada
Research Chair Janet Squires Doctoral
candidate Faculty of Nursing University of
Alberta KU09 Wales, UK June 24-26, 2009
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ACT overview

• 59 items representing 8 modifiable dimensions of
  context
• Currently
• 3 versions
• Adults (acute care)
• Pediatrics (acute care)
• Long term care
• 6 groups
• Healthcare Aides (LTC only)
• Nurses
• Allied
• Physicians
• Specialists/Educators
• Managers

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Initial ACT development

• Selection of a conceptual framework
• Critical review of literature
• Promoting Action on Research Implementation in
  Health Services (PARiHS) framework as initial
  guide
• Conceptual refinement
• Addition of concepts to incorporate teams
  understanding of other relevant aspects of
  organizational context
• Conceptual and operational definitions developed

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Initial development

• Survey construction
• Item construction
• Initially versions for 5 groups in adult acute
  care (RN/LPN, MD, Allied, Managers, Educators)
• Feasibility modifications
• Survey administration and debriefing sessions
  were held with members of the five groups
  (summer, 2006)
• Modifications made based on debriefing feedback
• Question clarity
• Revision of examples
• Length/respondent burden
• Response process validity evidence

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Framework
PARiHS Framework
Research implementation
Leadership

Adding to context
Context

• Slack
• Interactions
• Resources
• Social capital

Culture


Facilitation
Evaluation
Evidence

• Attitude
• PSA
• Belief suspension
• MBI
• SF-8

Individual attributes
Kitson, et al., 1998, QSHC Rycroft-Malone et al,
2002 (J Adv Nurs)
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ACT Framework
Leadership

Adding to context
Context

• Organizational slack
• Formal interactions
• Informal interactions
• Structural electronic resources
• Social capital

Culture
Evaluation
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Structure of ACT

• 1. Leadership
• 6 items scored on a 5-point Likert like scale
• Concepts reflected in items openness, optimism, s
  elf control,  empathic, developing 
  others, conflict management 
• e.g., The leader calmly handles stressful
  situations
• 2. Culture
• 6 items scored on a 5-point Likert like scale
• Concepts reflected in items recognition, autonomy
  , worklife balance, development opportunity, focus
   on service/mission, support 
• e.g., I receive recognition from others about my
  work
• 3. Evaluation
• 6 items scored on a 5-point Likert like scale
• Concepts reflected in items data access, informal
   data review, formal data review, action planning,
   performance monitoring,  benchmarking
• e.g., Our team routinely discusses this data
  informally

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Structure of ACT

• 4. Formal Interactions
• 5 items scored on a 5-point frequency scale
• Concept reflected in items Interactions with
  others through engagement in formal
  organizational (unit) activities
• e.g., Team meetings about residents
• 5. Informal Interactions
• 6-9 items scored on a 5-point frequency scale
• Concept reflected in items Interactions with
  others through engagement in informal
  organizational (unit) activities
• e.g., Other professionals in my discipline
• 6. Social Capital
• 6 items scored on a 5-point Likert like scale
• Concepts reflected in items bonding, bridging,
  linking
• e.g., People in my group share information with
  others in the group

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Structure of ACT

• 7. Structural and Electronic Resources
• Structural 9 items scored on a 5-point frequency
  scale
• Electronic 3 items scored on a 5-point frequency
  scale
• Concept reflected in items availability/use of st
  ructural and  electronic resources
• e.g., Policy and procedure manuals   
• 8. Organizational Slack
• 9-11 items consisting of 3 sub-scales
• Staffing (2-3 items scored on a 5-point Likert
  like scale assessing availability of adequate
  staffing resources
• Space (3-4 items scored on Likert and frequency
  scales assessing availability and use of space
• Time (4 items scored on a 5-point frequency scale
  assessing availability and use of time)
• e.g., Have time to do something extra for
  residents

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Validation
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The Standards1 approach to validity
A unitary approach to validity assessment where
empirical results are classified as supporting
(or refuting) validity
Validity Source Explanation
Content To what extent does the content of the items represent the content of the domain? e.g., expert panel, CVI
Response Process To what extent do the respondents responses fit the intended construct? Do respondents interpret, process, and elaborate upon item content and is this behaviour in accordance with the construct? e.g., revise items from pretest, interview to confirm instrument
Internal Structure To what extent do the relationships among the items match the construct as operationally defined and do the data support dimensionality? e.g., factor analysis, item analysis (IRT)
Relationships with other Variables What is the nature and extent of the relationships between instrument scores and variables it is expected to correlate with or predict variables it is not expected to correlate with or predict e.g., correlations, regression
1 Standards for Educational and Psychological
Testing. AERA 1999.
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Initial validation (AKUTE1 study)

• Acute Care (Adult) setting
• 4 teaching hospitals in Alberta
• 5 professional provider groups (N453)
• Reliability (alpha)
• Range .65 (formal interactions) to .92
  (evaluation)
• All but one gt.70
• Validity (internal structure evidence)
• Factor analysis (PCA with Varimax rotation)
• 14 factor solution 67 of the variance
• ACT core (culture, leadership, evaluation
  31.95 of variance)

1AKUTE Estabrooks, Norton, Birdsell, Cummings,
Newton. AHFMR funded
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Second validation study (pilot wave 1 CIHR Team
in Childrens Pain)

• Survey revisions made based on pilot findings
  from four pediatric acute care units in Alberta
  (response process)
• Validation study - acute care (pediatric) setting
• 8 pediatric hospitals across Canada
• 5 professional provider groups (N1248)
• Validation with Nurses (N850)
• Reliability (alpha)
• Range .60 (formal interactions) to .91
  (evaluation)
• All gt.70 except for formal interactions (.60) and
  space (.65)

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Second validation study

• Validity (internal structure evidence)
• Item assessment
• Item-total statistics remained stable
• Factor analysis
• 14 factor solution 61 of the variance
• ACT core (culture, leadership, evaluation
  27.63)
• Some realignment of items (formal/informal
  interactions)

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Second validation study

• Validity (relationship with other variables
  evidence)
• Correlation analysis
• All ACT dimensions significantly correlated with
  IRU
• Range r.052 (OS-staff) to .272
  (structural/electronic resources)
• Regression Analysis
• 7/8 ACT dimensions predict research use (at
  hospital level) at plt.10 (exception
  structural/electronic resources)

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Additional Validation(CapitalCare studuy)

• Pilot Study
• 91 LPNs and HCAs in 4 long-term care units
• Extensive feasibility testing (response process
  validity evidence)
• Reliability
• Alpha gt .70 for 7/8 dimensions (formal
  interactions revised)
• Alpha range 0.50 (formal interactions) to 0.96
  (evaluation)

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Ongoing plans

• The ACT currently under revision
• i.e., harmonize across versions , reduce the
  number of versions
• Planned validation
• Psychometric assessment in new populations and in
  settings
• Further psychometric assessment
• Item Response Theory (IRT)
• Confirmatory Factor Analysis (CFA)
• Ongoing work re scoring of dimensions
• Assessment of translated versions (e.g., Swedish,
  French)

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