How to deal with context? A context-mapping tool for quality and safety in nursing homes and homecare (SAFE-LEAD Context)

Objective The objective of this paper is to develop a context-mapping tool (SAFE-LEAD Context) adapted to the nursing home and homecare setting. These two contexts represent a substantial variability, but studies focusing on the types and roles of contextual factors in quality and safety in these care settings are lacking. Results We conducted a step-wise collaborative design process consisting of mapping of key contextual factors as perceived by managers in Norwegian nursing homes and homecare, then created a draft tool discussed in a consortium workshop with co-researchers, and ran an international cross-country comparison. The SAFE-LEAD Context tool is inspired by the Consolidated Framework for Implementation Research (CFIR). The tool incorporates factors describing the outer setting of nursing homes and homecare at the national and local levels, in addition to factors describing the inner setting. The tool is flexible yet more detailed than current frameworks and capable of grading and describing the included contextual factors over time in the nursing home and homecare settings. A systematic approach using the SAFE-LEAD Context tool will support and improve the understanding and evaluation of quality and safety improvement interventions.


Introduction
There is a dearth of literature about what kind of and how contextual factors influence knowledge translation [1][2][3][4] and the continuous quality and safety work in healthcare services [5][6][7][8][9]. Context can be conceptualized as a set of circumstances or factors that surround improvement efforts [10], and can refer to both the inner (internal) and outer (external) settings of an organization. Internal organizational factors include structural characteristics (e.g., location and size), the local working environments of teams and leadership, and the organizational culture and implementation climate. External factors include applicable laws, regulatory requirements, external policies and incentives, funding structures [8], patient organizations, payers, and professional organizations [11]. Context is not independent of the actors within specific healthcare settings; rather, it is something that can be acted upon and changed [12].
In the international body of literature, most of the research on improving quality and safety in healthcare is conducted in the hospital setting so we know less about other settings [13]. Health services provided by nursing homes and homecare are essential in most countries, and the quality and safety work in these settings is attracting increased attention [14]. The different settings that Open Access BMC Research Notes *Correspondence: siri.wiig@uis.no; eline.ree@uis.no 1 SHARE-Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway Full list of author information is available at the end of the article nursing home and homecare services operate within vary greatly, and there are few studies of the types and roles of contextual factors in these care settings [15][16][17]. Therefore, the objective of this paper is to develop a contextmapping tool (SAFE-LEAD Context) that is tailored to the nursing home and homecare settings.
Our SAFE-LEAD Context tool was developed as part of the SAFE-LEAD project [18]. It is inspired by McDonald's [8] operationalization of the Consolidated Framework for Implementation Research (CFIR) [10]. The CFIR focuses on implementation research and consists of five domains (1) intervention characteristics; (2) outer setting; (3) inner setting; (4) characteristics of the individuals involved; and (5) implementation. We extended, developed, and adapted the domains of inner and outer settings to the nursing home and homecare settings. In the CFIR framework [10], outer setting consists of: • Patient needs and resources • Cosmopolitanism (extent of external network) • Peer pressure (to implement interventions) • External policies and incentives The inner setting refers to: • Structural characteristics • Networks and communication • Culture • Implementation climate and readiness

Development setting
In Norway, municipalities are by law responsible for providing nursing home and homecare services to residents, and the managers have a clearly defined role in ensuring service quality and safety [19,20]. The requirements for quality and safety are the same across all municipalities, although size, geographical location, and competence varies greatly from large cities to small rural areas.

A step-wise collaborative design process
In a collaborative development process, we applied the design steps depicted in Fig. 1, which were: (1) qualitative interviews with managers in nursing homes and homecare in Norway; (2) input from co-researchers with broad experience from the Norwegian nursing homes and homecare services; (3) assessment of CFIR and drafting of the tool; (4) workshops with researchers, user representatives and practice-based co-researchers; (5) iterative cross-country comparison of tool contents; and (6) finalizing the SAFE-LEAD Context tool.
Step 1 consisted of a qualitative interview study with nine nursing home and homecare managers in six Norwegian municipalities (large, small, rural, city). The participants were top and middle managers within those municipalities, and represented different regions, geographical locations and institutions of different sizes. All of these managers were educated as registered nurses and had experience as frontline staff. The participants were purposely selected to maximize their contextual diversity. Residents and frontline staff were not included in step 1 as the focus was managers' experience with working on quality and safety. Three practice-based co-researchers in the SAFE-LEAD project consortium working in different Norwegian regions recruited the participants. The interview guide included open questions regarding which factors managers perceived as important for their work with quality and safety, and topics such as external factors, economy, and structure. Each interview lasted approximately 45 min and was audiotaped. All interviews were transcribed and subjected to thematic analysis [21]. For all themes, different contextual factors were noted to specify potential topics or questions to be included in the context-mapping tool (see Table 1). This was discussed in an analysis workshop attended by SW, ER, TJ, LHT, EHR, and additional project members.
In step 2, we asked the three co-researchers to provide written notes (complementing the thematic analysis), on what they considered the ten most important contextual factors, based on their diverse background and experience as managers and healthcare professionals (nurses) in primary care (nursing home, homecare, development center for institution and homecare services).
In step 3, based on the factors identified from the thematic analysis, the written notes from the co-researchers, and assessment of the CFIR, we assessed what additional factors that should be included to cover the nursing home and homecare settings. SW, ER, EHR, and TJ drafted a first version of the context-mapping tool.
In step 4, we conducted a context-mapping design workshop with all the Norwegian consortium partners and co-researchers to obtain feedback on the draft version. In this workshop, user representatives including one senior representative and one Patient and user ombudsman participated. Both are members of the project consortium with in depth knowledge of the nursing home and homecare settings. Here we discussed the dimensions going into the tool, how data could be collected to map the factors over time, and whether those factors could be assessed on a five-point scale.
In step 5, we conducted an iterative cross-country comparison of tool contents with the Dutch researchers RB and HvB in the consortium, who assessed its relevance from an international perspective and suggested additional factors. The Dutch researchers focused on whether the tool included relevant contextual factors to enable a cross-country comparison of quality and safety work and interventions.
Step 5 was supported by a review of macro-level factors for understanding quality and safety improvement efforts across countries [22]. In step 6, we finalized the SAFE-LEAD Context tool and prepared it for empirical testing.

Key contextual factors
Based on the analysis of the nine manager interviews (step 1), Table 1 depicts the identified common themes and specific contextual factors. The main issues were related to the size of the municipality, the size of the nursing home or homecare service provider, and geographical location. Organizations were sometimes considered too large or small, with long driving distances to a hospital or to the service users in the rural areas, and this made a manager's work on improving quality and safety more complicated. Other factors that appeared important pertained to care coordination, collaboration, and relation to the elected politicians in the municipality. Budget constraints, difficulties with collaboration and coordination across service levels were noted as challenges in daily operations. External demands in terms of regulation, national guidelines, and national policy documents both supported and hindered the local improvement work. Policy documents pinpointing the role of managers' responsibility for improving care quality and safety, supported their effort and contributed to put the topic on the agenda both within the nursing home or homecare organizations, and at the municipal level. At the same time, the external demands could be overwhelming due to resource constraints and limited competence. Access to relevant competence and capacity varied across the municipalities and recruitment could be especially difficult in rural areas. Access to resources (time and money) was furthermore focused, and there was a consensus that chronic lack of time and increasing demands for efficiency hampered managers' ability to devote sustained attention to the improvement of quality and safety.
The structural aspects related to status of IT systems, incident reporting systems, checklists, and documentation varied among the participants. Many emphasized the importance of incident reporting systems, but there was a range of IT systems and access to computers among healthcare staff. The managers also considered cultural factors and leadership as key themes for the work on quality and safety. They acknowledged their responsibility as role models and the importance of building an understanding for the need for improving quality and safety in tandem with the team of healthcare professionals.
In step 2 of our design process, the practice-based coresearchers confirmed the contextual factors summarized in Table 1, focusing on the following factors: • Collaboration and relations: (a) between local politicians and managers; (b) among different healthcare professionals (nurses, doctors, physiotherapists, and occupational therapists); and (c) with research institutions • Dedicated resources to quality and safety (competence, time, personnel) • Continuity of care within and across service levels • Nurse-patient ratio • Location, travel distance to hospital • Digital infrastructure Table 2 presents the final version of the SAFE-LEAD Context tool for identifying contextual factors for quality and safety in nursing homes and homecare. The tool includes factors describing the outer setting at the national and local levels, in addition to factors describing the inner setting. The tool opens for grading and describing the included contextual factors over time using a scale from 1 (low degree/small) to 5 (high degree/large). We added the grading possibility to enable descriptive comparison between different units involved in the mapping or to track potential change over time. This possible specification of degree adds to the original CFIR, which mentions "the degree of which" for several constructs but does not include any specific grading. For some factors, this grading is not applicable, and we therefore added a column for free text assessment and/or description of the factor.

Discussion
The success of quality and safety efforts depends on contextual factors [23][24][25][26]. Most research on the topic has been conducted in hospitals so less is known about the role of contextual factors in nursing homes and homecare. In this paper, we have demonstrated our step-wise collaborative design process in developing a contextmapping tool. We mapped key contextual factors as perceived by managers, co-researchers, user representatives, international researchers, and developed SAFE-LEAD Context, inspired by the CFIR, to support understanding and evaluation of improvement efforts in the nursing home and homecare settings. The CFIR framework was chosen as a basis for the SAFE-LEAD Context tool, as it provides a list of constructs and argues that each construct should be carefully reviewed and fitted to the setting at hand [10]. The SAFE-LEAD Context tool supports targeted context factor mapping in nursing homes and homecare, in a Norwegian and international perspective. We are confident that other researchers or practitioners can apply the tool or replicate its development. We argue Degree of actual involvement of user/patient/next of kin at system level (arenas, board, committees, survey, co-design) Patient/user centeredness Degree of user/patient centeredness in service provision Work schedule Degree of organizing of work schedule according to patient needs that using a similar collaborative development approach, including user-representatives and co-researchers, when adapting the CFIR or other frameworks, will support knowledge translation or intervention studies to improve quality and safety in their specific setting. The SAFE-LEAD Context tool is currently being tested in an intervention study including four nursing homes and four homecare services in Norway [18], and results including the evaluation of the tool will be published as part of the project publication plan.

Limitations
• This paper describes the development process of the SAFE-LEAD Context tool. This version has not yet been empirically tested for effectiveness and applicability • The sample of managers and practice-based coresearchers is limited and should be expanded to additional primary care settings • The sample could have included frontline staff, patients, and users • The international cross-country component should be expanded beyond researchers to managers and user-representatives from different countries Abbreviation CFIR: Consolidated Framework for Implementation Research.

Acknowledgements
We thank senior representative Elsa Kristiansen and patient and user ombudsman Torunn Grinvoll in the SAFE-LEAD project for input in the consortium workshop where we presented the draft context-mapping tool. We wish to thank SAFE-LEAD project team members Torunn Strømme, Lene Schibevaag, and co-researcher Berit Ullebust for their contribution to the data collection and analysis, and participation in the consortium workshop, giving input on the draft version of the context-mapping tool. We also thank the SAFE-LEAD project members Ingunn Aase and Marianne Storm, and co-researcher Anne Torhild Sandvik Pedersen for their contribution to the SAFE-LEAD study protocol.