Improving Wound Care in Residential Aged Care Facilities: Development, Validation and Use of a Novel Knowledge Translation Framework

ABSTRACT

Introduction

Wounds and skin conditions are common in residential aged care settings and can result in significant physical, psychosocial and economic impacts on residents and care systems. Ensuring high‐quality evidence‐based wound and skin care in residential aged care facilities is essential to promote resident well‐being. However, the integration of such practices is a complex knowledge translation endeavour, influenced by contextual challenges. A comprehensive, systematic and theory‐based framework can be used to guide the complex process. The aim of this study was to develop and validate a framework for wound care knowledge translation in residential aged care facilities.

Method

A multi‐method, three‐phase design was used. Phase 1 involved two systematic reviews to identify elements from theoretical and empirical perspectives, resulting in a draft framework. Phase 2 consisted of an online participatory design workshop with 10 key stakeholders to contextualise the elements identified in Phase 1. In Phase 3, a two‐round modified e‐Delphi process was conducted with 11 international experts to refine and validate the framework.

Results

The developed framework, which recognises knowledge translation as a process, comprises four vertical phases: pre‐implementation, implementation, evaluation and sustainment. Additionally, it includes four horizontal components: Process steps, Adoption process, Values as a moral compass and Engagement for individual behaviour change and team development. Consensus was reached on the ‘PAVE’ framework's comprehensiveness, relevance, usability and value for guiding knowledge translation in residential aged care facilities.

Conclusion

The PAVE framework offers a tool for implementation scientists, gerontology nurses and researchers to plan and guide knowledge translation for establishing evidence‐based wound and skin care practices in residential aged care facilities, improving the quality and safety of care to older people. The framework holds potential for broader application across various interventions and healthcare settings. Future studies should explore the PAVE framework's effectiveness in diverse healthcare settings.

Summary.

• What does this research add to existing knowledge in gerontology?

  • ○
    Implementation of evidence‐based practices is a complex process that can be guided by the PAVE framework as the first comprehensive and contextualised framework for use in residential aged care facilities.
  • ○
    The horizontal components in the PAVE framework can be employed collectively or individually, offering flexible application.
  • ○
    The PAVE framework uniquely integrated fundamental values to guide decision‐making and uphold holistic and dignified care to older people during the implementation process.
• What are the implications of this new knowledge for nursing care for and with older adults?

  • ○
    Gerontology nurses can use the PAVE framework to systematically approach the implementation of evidence‐based practices, leading to improved care outcomes and quality of life for older people.
  • ○
    The PAVE framework encourages a holistic focus, not just on clinical care, but also on team development, individual behaviour change and values important in providing person‐centred, dignified care for older people.
  • ○
    The framework's emphasis on ongoing evaluation and sustainment supports long‐term and sustained improvements in wound care quality.
• How could the findings be used to influence practice, education, research, and policy?

  • ○
    The PAVE framework is a tool that can be used to improve wound care at residential aged care facilities through systematic guidance of the implementation of evidence‐based interventions into practice.
  • ○
    Researchers can use the PAVE framework to plan for implementation research studies in residential aged care facilities.
  • ○
    The PAVE framework can provide a structure for gerontology nurses, healthcare practitioners and researchers to conduct a retrospective analysis of knowledge translation and practice change efforts to gain insights in successes and failures.

1. Introduction

The integration of evidence‐based care into routine healthcare practice is essential for improving health outcomes for older people and for enhancing the efficiency of healthcare systems. Evidence‐based care depends on successful knowledge translation that accounts for complex care environments. However, the implementation of evidence‐based wound care practices in residential aged care facilities remains limited—in part, due to fragmented and often incomplete guidance on how to navigate the complex process of knowledge translation in these settings. This paper presents the development and validation of a comprehensive theory‐based framework, known as the Process–Adoption–Values–Engagement (PAVE) framework, to guide knowledge translation for wound care practices in residential aged care facilities (RACFs).

Wound care in RACFs presents a complex clinical and organisational challenge. The occurrence of wounds in these settings can be substantial, with reports indicating prevalence rates of up to 78%, reflecting a combination of physiological, environmental and care‐related factors (Alam et al. 2021; Parker et al. 2020). Wounds are associated with significant consequences for older people, which include pain and restricted mobility in addition to psychosocial effects such as anxiety, depression and social withdrawal (Cowdell et al. 2023; Kodange 2021). These challenges also contribute to increased healthcare utilisation and financial burdens for individuals, families and the broader health system (Fleming et al. 2022; McCosker et al. 2019). Therefore, evidence‐based wound and skin care practices which have been shown to improve health outcomes through quality, person‐centred and dignified care should be implemented in RACFs (Parker et al. 2020; Völzer et al. 2023). However, many barriers exist to knowledge translation and the implementation of evidence‐based wound care practices in RACFs. Examples of these barriers are a lack of evidence‐seeking behaviour, poor documentation, limited organisational support and a lack of teamwork and resources (Lavallée et al. 2018; McArthur et al. 2021; Shayan et al. 2019). The complexity of the context for wound care in RACFs further challenges implementation processes (Levine et al. 2021). A range of wound types are widespread in RACFs since these facilities offer accommodation and healthcare on a continuum of dependence ranging from frail to relatively independent. Acute wounds such as skin tears are prevalent but also chronic and complicated wounds such as venous leg ulcers and pressure injuries among frail residents (Levine et al. 2021). Furthermore, several levels of nursing staff and the interprofessional team are involved for continued execution of a wound treatment plan (Sherman and Kamel 2019). Therefore, careful planning is required for successful implementation of evidence‐based wound and skin care interventions. Without theoretical approaches to guide and explain the complexities of the context and the knowledge translation process, change is less likely to be effective or sustained (Birken et al. 2018; Damschroder 2020).

Choosing the most appropriate theoretical approach for knowledge translation presents challenges, particularly for nurses unfamiliar with implementation science (Birken et al. 2017). Theoretical approaches usually guide specific elements of implementation and do not involve all components (Moullin et al. 2015). Therefore, multiple theories are often needed to navigate the implementation process, including planning, design, contextual analysis, strategy selection and evaluation (Moullin et al. 2015). A systematic theory‐based framework that considers all the elements has not yet been developed to guide knowledge translation for wound care practices in RACFs. The PAVE framework described in this paper is a novel guide that could ‘pave’ the way for the complex process of wound care knowledge translation in RACFs. Because the aim of the paper is to describe the overarching process of development and validation, the primary method and results are discussed per phase; but the in‐depth processes are not discussed here.

2. Development and Validation of the PAVE Framework

A multi‐method research design was used to develop and validate the PAVE framework. This approach enabled the initial identification of existing knowledge translation constructs from both theoretical and empirical perspectives, followed by their contextualisation for relevance and a refinement and validation of the framework. Figure 1 below depicts the three phases with the related methods used to develop and validate the framework.

FIGURE 1.

Phases of the PAVE framework development and validation.

2.1. Creating a List of Knowledge Translation Elements (Phase 1)

The structure of a best‐fit framework synthesis (Booth and Carroll 2015a) including two systematic reviews, was used to identify the important elements of knowledge translation in RACFs from the analysis of theoretical and empirical perspectives. A best‐fit framework synthesis allows for the initial development of a priori themes from theories, models and frameworks, against which data from primary studies are mapped (Carroll et al. 2011). This process allowed for the development of a list of knowledge translation elements with actionable delineations relevant to wound care in RACFs.

2.1.1. The First Systematic Review

The first systematic review of the best‐fit framework synthesis entailed the systematic identification of papers in peer‐reviewed journals, which reported on theories, models and frameworks that have been used for knowledge translation in RACFs. Theories, models or frameworks were included if they presented the evidence dissemination, evidence exchange and evidence application domains of knowledge translation in RACFs to improve the health care in RACFs. Sources from 1995 up to 20 May 2019 were identified through Boolean searches, using the ‘Behavior of interest; Health context; Exclusions; Models or Theories’ mnemonic BeHEMoTh (Booth and Carroll 2015b). The BeHEMoTh search strategy is a counterpart of the PICO search strategy but was specifically developed for a best‐fit framework synthesis review to guide systematic searching for theories, models and frameworks (Booth and Carroll 2015b). The search was not limited to a language but was restricted to publications in peer‐reviewed journals and was conducted by an information specialist on Academic Search Ultimate, Africa‐Wide Information, CINAHL with Full Text, ERIC, Health Source—Consumer Edition, Health Source: Nursing/Academic Edition and MEDLINE with Full Text. The search strategy can be found as Table S1.

The process of source selection and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis Protocols (PRISMA‐P) (see Figure 2) (Page et al. 2021). The search yielded 63 records and no duplicate records were found. The three authors independently screened titles and abstracts. Conflicts were resolved in a consensus meeting. During this process, 47 records were excluded, largely because the records did not report on knowledge translation, models, frameworks or theories. One full‐text paper could not be found. The three authors then independently assessed the remaining 15 full‐text papers for eligibility; conflicts were resolved during a meeting until consensus was reached. A further nine papers were excluded since they did not report on knowledge translation or on all domains of knowledge translation and were not relevant to the RACF context.

FIGURE 2.

PRISMA‐P flow diagram; the first systematic review process.

Two reviewers independently appraised the models and frameworks in the six remaining papers for their usability, testability, applicability and acceptability using the Theory Comparison and Selection Tool (T‐CaST) (Birken et al. 2018). The T‐CaST was user‐friendly and comprehensive as it allowed for comparing theories, models and frameworks (Birken et al. 2018) and for an objective selection of the most suitable theories, models and frameworks. The T‐CaST scores are reported in Table S2. One model, the Connected Learning model (Lekan et al. 2010), was excluded since its testability and applicability scored low and the overall T‐CaST score was 61.5% compared to the other model and framework scores, which ranged between 78% and 96.8%. Therefore, a final five papers were included for analysis and included the Quality Enhancement Research Initiative (QUERI) framework (Logan et al. 1999), the Promoting Action on Research Implementation in Health Services (PARiHS) framework (Perry et al. 2011), the Champions for Skin Integrity (CSI) model (Edwards et al. 2017), the Ottawa Model of Research Use (OMRU) (Rubenstein et al. 2000) and a model for implementing guidelines for person‐centred care (abbreviated as IGPCC) (Vikström et al. 2015).

Follow‐up searches on websites and citation searching were conducted to identify updated versions and reports of the five frameworks. The same screening process was followed, and another six reports were included for analysis, allowing a deeper understanding of the model and framework constructs. These included two reports on the CSI model (Edwards et al. 2010, 2015), a revised version of the OMRU framework (Graham and Logan 2004), the integrated‐PARiHS framework (i‐PARiHS) (Harvey and Kitson 2016) and two updated versions of the QUERI framework, namely the QUERI framework (Stetler et al. 2008) and the QUERI roadmap (Kilbourne et al. 2019). The characteristics of the included studies, reports, models and frameworks are available in Table S3.

The papers and reports were uploaded to ATLAS.ti (V.9) and the constructs and their meanings were extracted and coded. Iterative rounds of inductive and abductive thematic analysis led to the identification of commonalities and unique elements. The first review yielded seven themes, each with several sub‐themes and categories. The context theme yielded several contextual determinants but was not included in the PAVE framework since several comprehensive determinant frameworks already existed (Damschroder et al. 2022). However, the principle of assessing the context with a determinant framework was included as part of the pre‐implementation phase theme. Table 1 outlines the six themes, sub‐themes, categories and associated sources.

TABLE 1.

Themes, sub‐themes and categories of the best‐fit framework synthesis review.

Sub‐theme	Category	Theoretical/empirical source
Theme: Pre‐implementation phase
Build trusting relationships	None	OMRU; QUERI roadmap; i‐PARiHS framework
Assess, plan and secure support	Management support	OMRU; QUERI roadmap; CSI model
	Funding	OMRU; CSI model
	Advisory support	OMRU; QUERI roadmap; CSI model
Initiate	Problem‐identification	QUERI framework; QUERI roadmap; Model of IGPCC
	Search scientific evidence	OMRU; QUERI framework; QUERI roadmap; Model of IGPCC; CSI model
	Propose draft intervention	OMRU; QUERI framework
Assess	Identify stakeholders and their roles	OMRU; QUERI roadmap; CSI model
	Explore evidence‐based practice gap	OMRU; QUERI framework; Model of IGPCC
	Assess contextual barriers and facilitators	OMRU; QUERI framework; QUERI roadmap; i‐PARiHS framework; Model of IGPCC; CSI model
Co‐design the intervention and implementation plan	Choose an area of improvement	QUERI framework; QUERI roadmap; i‐PARiHS framework; Model of IGPCC; CSI model
	Revise intervention to fit practice	OMRU; QUERI roadmap
	Develop implementation and evaluation protocol	OMRU; QUERI framework; QUERI roadmap; Model of IGPCC; CSI model
	Develop educational material	QUERI framework; CSI model
	Prioritise barriers/facilitators	Empirical study: Beeckman et al. (2013)
	Develop documentation	Empirical studies: Olsho et al. (2014), Horn et al. (2010)
Theme: Implementation phase
Monitor, assess, feedback and adapt (MAFA) cycles	Monitor and evaluate	OMRU; QUERI framework; QUERI roadmap; Model of IGPCC; CSI model
	Assess barriers and facilitators to adoption	OMRU; PARiHS/i‐PARiHS framework
	Feedback	QUERI roadmap; Model of IGPCC; CSI model
	Adapt and renew the application	OMRU; QUERI framework; QUERI roadmap; CSI model
Facilitation	None	OMRU; QUERI framework; i‐PARiHS framework; Model of IGPCC; CSI model
Adoption process	None	OMRU; QUERI framework
Implementation strategies	Mechanisms of implementation strategies	OMRU; QUERI roadmap; CSI model
	Frequently used implementation strategies	OMRU; QUERI framework; QUERI roadmap; i‐PARiHS framework; Model of IGPCC; CSI model
Theme: The evaluation of outcomes
Outcomes	Resident and family outcomes	OMRU; QUERI framework; QUERI roadmap; PARiHS/i‐PARiHS framework; Model of IGPCC; CSI model
	Staff outcomes	OMRU; QUERI framework; Model of IGPCC; CSI model
	Organisational outcomes	OMRU; QUERI framework; QUERI roadmap; CSI model
	Service outcomes	QUERI roadmap
	Implementation outcomes	OMRU; QUERI framework; QUERI roadmap; Model of IGPCC; CSI model
	Sustainability	PARiHS/i‐PARiHS framework; Model of IGPCC
Evaluation using relevant research designs	None	QUERI framework
Theme: The sustainment phase
Continued use of the evidence‐based practice	Continued use requires ownership	QUERI roadmap
	A plan to support continued use	OMRU; QUERI framework; QUERI roadmap; Model of IGPCC; CSI model
	Continued monitoring	QUERI roadmap; CSI model
Cyclic nature of improvement, a culture of innovation	None	QUERI roadmap; Model of IGPCC; CSI model
Intervention scale‐up and spread	None	CSI model
Theme: The intervention
Intervention characteristics	Accessibility	CSI model
	Adaptability	OMRU; QUERI framework; i‐PARiHS framework; Model of IGPCC; CSI model
	Clarity	OMRU; QUERI roadmap; i‐PARiHS framework
	Complexity	OMRU; i‐PARiHS framework; Model of IGPCC; CSI model
	Comprehensiveness and structure	QUERI framework
	Cost‐effective	Model of IGPCC
	Scientific robustness (evidence‐based) and regularly updated	PARiHS framework; CSI model
	Trialability	OMRU; i‐PARiHS framework
Sources of intervention content	Health care providers' experiences	PARiHS/i‐PARiHS framework; Model of IGPCC
	Resident and family preferences, needs and resources	PARiHS/i‐PARiHS framework; Model of IGPCC
Theme: The stakeholders
Stakeholder types	Adopters	OMRU
	Care workers	CSI model
	Educators	OMRU; CSI model
	Facilitators	OMRU; QUERI framework; PARiHS/i‐PARiHS framework; Model of IGPCC; CSI model
	Managers	OMRU; i‐PARiHS framework; CSI model
	Medical doctors	CSI model
	Nursing staff	QUERI roadmap; i‐PARiHS framework; CSI model
	Other RACFs	CSI model
	Policymakers	OMRU; QUERI framework; QUERI roadmap
	Public	OMRU; CSI model
	Rehabilitation health professionals	OMRU; CSI model
	Residents and their families	OMRU; QUERI framework; QUERI roadmap; PARiHS/i‐PARiHS framework; Model of IGPCC; CSI model
	Researchers	QUERI framework; QUERI roadmap; Model of IGPCC; CSI model
	System‐level research and quality improvement organisations	OMRU; QUERI framework
	IT experts	Empirical study: Sharkey et al. (2013)
	Medical insurance companies	Empirical studies: Abel et al. (2005), Baier et al. (2003), Horn et al. (2010)
	Minimum Data Set nurses	Empirical study: Horn et al. (2010)
	Pharmacists	Empirical study: Vu et al. (2007)
	Quality improvement staff	Emperirical studies: Abel et al. (2005), Baier et al. (2003), Sharkey et al. (2013)
	Wound care experts	Empirical studies: Horn et al. (2010), Kwong et al. (2011), Sharkey et al. (2013)
Team roles	Advisory team role	CSI model
	Facilitation team role	PARiHS/i‐PARiHS framework; CSI model
	Interprofessional team role	CSI model
	On‐site implementors' role	Model of IGPCC; CSI model
	Researchers' role	QUERI framework; CSI model
Theme: The clinical wound care workflow
Establish a baseline through assessment	None	Empirical studies: Abel et al. (2005), Baier et al. (2003), Beeckman et al. (2013), Edwards et al. (2017), Fossum et al. (2013), Kennedy (2005), Kwong et al. (2011), Kwong et al. (2020), Lyman (2009), Olsho et al. (2014), Righi et al. (2020), Vu et al. (2007)
Complete, clear, consistent and accurate documentation is a prerequisite	None	Empirical studies: Ellis et al. (2006), Horn et al. (2010), Olsho et al. (2014), Sharkey et al. (2013)
Referral to relevant specialists and health care professionals	None	Empirical study: Kwong et al. (2011)
Individualised prevention and treatment plan	None	Empirical studies: Beeckman et al. (2013), Kwong et al. (2020), Lyman (2009), Righi et al. (2020), Sharkey et al. (2013)
Use of clinical decision‐support tools	None	Empirical studies: Beeckman et al. (2013), Fossum et al. (2013), Horn et al. (2010), Olsho et al. (2014), Sharkey et al. (2013)
On‐going monitoring and the cyclic nature of the clinical wound care workflow	None	Empirical studies: Ellis et al. (2006), Horn et al. (2010), Kwong et al. (2011), Lyman (2009), Olsho et al. (2014), Sharkey et al. (2013)

Abbreviations: CSI, Champions for Skin Integrity; IGPCC, Implementing Guidelines for Person‐Centred Care; MAFA, Monitor, Assess, Feedback, Adapt cycle; OMRU, Ottawa Model of Research Use; PARiHS, Promoting Action on Research Implementation in Health Services; QUERI, Quality Enhancement Research Initiative.

2.1.2. The Second Systematic Review

The second systematic review entailed the systematic identification of empirical studies with evidence of effective knowledge translation improving wound care in RACFs. A similar search process to the first review was used to search for peer‐reviewed journal articles from 1994 to 1 October 2020, on Scopus, Web of Science and EBSCOhost electronic databases Academic Search Ultimate, Africa‐Wide Information, CINAHL with Full Text, ERIC, Health Source—Consumer Edition, Health Source: Nursing/Academic Edition, and MEDLINE with Full Text. The search was conducted from 1994 since this was the year of some of the earliest implementation studies in wound care (Luker and Kenrick 1995; Flanagan 2005). A Boolean search string was developed based on the Population, Concept, Context (PCC) mnemonic (Peters et al. 2020). The second review's search strategy is included in the Table S4.

Following the de‐duplication and independent screening of the 1116 records, 18 articles met the inclusion criteria, namely an empirical study with evidence‐based interventions improving wound care provided to older people in RACFs. Papers were excluded if the intervention was surgical and did not have a nursing focus, and if the study aimed to test the effectiveness of a wound dressing or drug. The study had to have at least one implementation strategy and at least one effective wound care outcome. A further three studies were excluded following a quality appraisal with the Johns Hopkins Nursing Evidence‐Based Practice Research Evidence Appraisal Tool (Dearholt and Dang 2012). Two reviewers independently conducted the quality appraisal, followed by a discussion to reach consensus. A third reviewer appraised the papers if the first two reviewers did not agree regarding the quality appraisal score. The quality appraisal scores can be found as Table S5 and the characteristics of the 15 included studies as Table S6. The PRISMA‐P flow diagram for the second review is provided in Figure 3.

FIGURE 3.

PRISMA‐P flow diagram, second systematic review process.

The remaining 15 articles were abductively analysed according to the themes, sub‐themes and categories derived from the first review. Another theme, ‘the clinical wound care workflow’, emerged from the data and was developed into a separate conceptual model (see Figure S1). This clinical wound care workflow model can be used as a tool to guide the necessary redesign of clinical processes when introducing new evidence‐based wound care practices. It consists of three main steps, arranged in a cyclic manner: (1) holistic wound‐specific and risk assessments using validated tools consistently, (2) identification of available resources and (3) collaborative adjustment of the treatment plan by the care team. Referral and record keeping are integral to the process as they remain continuously relevant. At the centre of the workflow are key sources of information, these being research evidence, patient and family preferences and clinical experience.

Eight additional sub‐themes with specific relevance to the pre‐implementation and stakeholder themes, originated from the abductive analysis. The final list of themes, sub‐themes and categories as outlined in Table 1 were used in the next phase of the study to contextualise the elements for a framework specific to wound care knowledge translation in RACFs.

2.2. Contextualisation of the Elements (Phase 2)

The purpose of the second phase was to contextualise the identified framework elements through an online participatory design workshop. The presenters of the workshops adhered to the participatory design principles of democracy and mutual learning to integrate the end‐users' values into the framework and enhance its acceptability to stakeholders (Frauenberger et al. 2015; Vandekerckhove et al. 2020).

A stakeholder analysis was conducted before the workshop to identify the key stakeholders who are indirectly and directly involved with wound care in South African RACFs. These key stakeholders could provide perspectives on the realities of wound care and change processes in RACFs to contextualise the framework elements. The stakeholder analysis involved interviews with 14 RACF nurse managers since they have unique insights into the networks of stakeholders involved with wound care in RACFs. Participants were sampled from the identified key stakeholder categories through purposive and snowball sampling. In addition to being directly involved (patient care) or indirectly involved (in supervision, administrative management, family support, research) with wound care in RACFs, inclusion criteria included the ability to converse in English, as well as having access to a computer with an internet connection and being willing to take part for the full duration of the workshop. Aligned with sample sizes recommended for online workshops, the researcher aimed for a sample size of seven to thirteen (Ørngreen and Levinsen 2017). Ten stakeholders participated in the workshop; these being two nurse managers, a general administrative manager, a social worker, a dietician, an occupational therapist, a family member, a wound care practitioner, a researcher/educator and a general medical practitioner.

The workshop was conducted online on Blackboard Collaborative Ultra, a web‐based conferencing platform (Blackboard Incorporated 2021), over 2 days in August 2021. The following three data sets were collected: (1) barriers to change for evidence‐based wound care in nursing homes, (2) a set of values regarded as most important in caring for the older people with wounds at RACFs and (3) the relevance and importance of the draft framework's elements. The first data set (barriers) was collected on a virtual whiteboard on Blackboard Collaborative Ultra. Participants posted words and phrases indicating the barriers they experienced. The posts were followed by facilitated discussions to further explore the barriers; these discussions were audio‐recorded and transcribed. The themes from the whiteboard posts were used to deductively analyse the narrative data, while new information was analysed inductively to develop new themes. Table 2 provides the themes and supporting verbal quotations. These findings on the barriers were used to confirm the relevance of strategies in the PAVE framework for a contextualised tool.

TABLE 2.

Barriers to change for evidence‐based wound care in RACFs.

Theme	Participant quote	Strategy in the revised, validated PAVE framework
Lack of knowledge and training in wound care	‘People may leave our home and go to the hospital … and they come back with wounds, and we have to treat those wounds …. and …. we don't really have the knowledge to treat it and we don't really have the resources to treat it.’ (General Administrative Manager)	Engagement component: Individual behaviour changed by enhancing capability and motivation and creating opportunities (through improvement of organisational capacity and support)
Resistance to change	‘I think it is the idea that registered nurses have and that is to work in an old age home is a very nice peaceful job, it is not hard to work in an old age home.’ (Nurse Manager)
Shortage of staff	‘Some of them [RACFs in rural areas] don't even have registered nurses.’ (Nurse Manager)
Lack of resources for wound care	‘But nowadays the average older person in a residential care facility, even can't afford proper wound care.’ (Social Worker)
Lack of standards for wound care	‘I asked some managers this week and they said what they actually do, they do the best that works, if it works good, they try it, but in severe cases they usually refer it to the private wound care specialist.’ (Social Worker)
Lack engagement of all staff members	‘Without from the bottom involvement we just didn't get anywhere, until we brought in everybody and got their opinion.’ (Occupational Therapist)	Engagement of all adopters through continuous agreement discussion during planning, acting, monitoring and reflection

The purpose of collecting a value set was two‐fold. The first was to establish the values with which to align a future knowledge translation project for evidence‐based wound care at an RACF, and the second was to establish the values that informed the framework's content and design. The second data set (value set) was collected through a sequential process. Initially, an anonymous pre‐workshop survey was conducted to identify the top 10 values using the ‘System for Survey‐based Evaluation in Education’ (EvaSys) platform version V8.0, (Electric Paper Evaluation System GmbH). A discussion during the workshop further explored the meaning of these values, followed by another EvaSys survey to rank the priority values, the results of which are detailed in Table 3.

TABLE 3.

Key stakeholders' (n = 9) priority values in caring for older people at RACFs.

Value	Rank on a scale of 1–10
Preserving dignity	9.22
Compassion and patience	8.78
Holistic care	7.67
Competence	5.56
Teamwork	4.89
Commitment	4.67
Quality care	4.33
Professionalism	3.78
Accountability	3.22
Cost‐effectiveness	2.89

The final value clarification process involved a post‐workshop member checking on a shared Word document to confirm and augment the stakeholders' interpretations of the priority values. The values were integrated as the foundation of the PAVE framework to guide the decision‐making throughout knowledge translation processes, to maintain the focus on dignified holistic quality care of the older person.

The third data set included narratives from facilitated workshop discussions. These discussions primarily focused on the practical realities and challenges of knowledge translation in RACFs. Audio recordings of the workshop discussions were transcribed verbatim and narrative data were labelled with descriptive codes related to the framework elements. In addition, poll responses were collected on Blackboard Collaborative Ultra to yes/no questions and Likert‐scale questions regarding the importance and relevance of framework elements. An element's inclusion in the framework depended on majority agreement on its importance; if the discussions did not suggest exclusion from the framework.

The workshop discussions offered limited new insights into the specific steps of knowledge translation. The need for clear stakeholder engagement and team development strategies in the framework was emphasised. An interprofessional team approach and researcher involvement were unanimously deemed important (100% agreement). However, flexibility in team development was recommended, acknowledging the frequent unavailability of some stakeholders, particularly in rural areas.

Most participants (80% vote) favoured involving a core team in the co‐design of the intervention from the start of the knowledge translation process. Discussions also highlighted the importance of involving all RACF care staff to ensure buy‐in and commitment. While co‐design was broadly supported, participants suggested that competence might be a prerequisite.

The workshop discussions informed the preferred framework structure, aligning with stakeholders' desire for a systematic approach. The framework was organised into pre‐implementation, implementation, evaluation and sustainment phases in a linear arrangement. The Process, Adoption, Values and Engagement components play a role during each phase and were depicted in horizontal rows below the phases. The adoption process reflects the Normalisation Process Theory (NPT) constructs, namely sense‐making, engagement and commitment, collective action (teamwork) and reflexive monitoring. The NPT was selected as the overarching theory of change for this framework due to the absence of a theory of change in the initial review and considering its relevance to the barriers and constructs identified in the data sets. The NPT explains that complex interventions can be embedded or integrated into daily practice through the collective work of people who are engaged (May et al. 2009, 2022). People commit to the change process when they make sense of it and can see its value (May et al. 2009, 2022). For example, in RACFs, nurses and care staff work as a team to provide 24‐h care according to a care plan. When a new evidence‐based risk assessment tool for pressure injury prevention is introduced into daily practice, it is essential that all team members comply and understand the purpose of the tool and their specific roles and responsibilities in its use. Therefore, the NPT explains that staff are unlikely to commit to the change if they do not believe in the value of the new tool or do not understand how to use it, which may undermine teamwork and hinder adoption into routine practice.

Following the framework's development, member‐checking with six participants led to minor adjustments, confirming the framework's structure and content for the subsequent phase: expert validation. The other four workshop participants were not available for the member‐checking.

2.3. Validation of the Framework (Phase 3)

Expert validation of the framework was done through a modified e‐Delphi method. This approach valued collective insights from both South African and international experts. Iterative rounds enabled panellists to refine their opinions, informed by feedback from other panellists (Fink‐Hafner et al. 2019). The e‐Delphi was modified by excluding an initial open round and was conducted online with open‐ended and Likert‐scale questions (Datta et al. 2021; Yoo et al. 2022). Consensus of ≥ 80% on all items was achieved after two rounds.

The 15 panellists were purposively selected for expertise in implementation, care of older people and wound care research, in line with guidelines by Waggoner et al. (2016) and Yoo et al. (2022). Eleven panellists participated in the first Delphi round and six in the second round. Panellists were published authors from Australia, Ireland, the United Kingdom, Sweden, the United States, South Africa and Zimbabwe. One participant did not complete the demographic information. Ten participants held doctorates and, with the exception of one participant, all were university academics. Their professional backgrounds included a medical doctor, six nurses, an occupational therapist and a pharmacist, while two did not disclose their professional backgrounds.

Panellists completed the survey on the EvaSys platform. Eight questions were designed to elicit judgement of the framework's structure, its fit for purpose and ease of use. These questions drew on T‐CaST's usability, testability and applicability criteria (Birken et al. 2018) and on validation criteria by Nordin et al. (2012), focusing on the relevance, comprehensiveness and clarity of elements and their interconnections within the framework. Responses were collected using a four‐point Likert scale, ranging from ‘strongly disagree’ to ‘strongly agree’, and an open‐ended question was included to elicit suggestions for improvement. To ensure technical reliability, a pre‐test survey preceded the first e‐Delphi.

A link for the first survey was sent to 15 participants in November 2021. Following a 14‐day period and a subsequent reminder, seven responses were received. An extension led to 11 responses received within 25 days. The PAVE framework was revised based on the responses to the first Delphi round. For the second survey, the phrasing of one question was changed from ‘simplicity of the framework’ to ‘clarity of the framework’ based on a panellist's request. The second survey, incorporating panellists' suggestions, was then circulated. This subsequent round extended over a longer period, concluding in 9 additional days with six panellists contributing.

EvaSys generated a report detailing the narrative responses and descriptive statistics. Agreement per item was determined by the proportion of panellists choosing ‘agree’ or ‘strongly agree’ divided by the total respondents per question. Consensus required an agreement index of ≥ 0.8, aligning with rigorous standards cited in literature (Hong et al. 2019; Nasa et al. 2021; Waggoner et al. 2016). Additionally, the median with a value of three reflected majority agreement (Niederberger and Spranger 2020). The e‐Delphi results are summarised in agreement indexes and medians (Table 4).

TABLE 4.

Delphi survey round 1 and 2 agreement indexes and medians.

Item	Round 1 (n = 11)		Round 2 (n = 6)
	Agreement index	Median	Agreement index	Median
Structure as a whole
1. Comprehensive enough to guide knowledge translation	0.9	4	1	3
2. Relevance of the conceptual structure	0.9	4	1	3
3. Logical flow of the conceptual structure	1	4	1	3
Fit for purpose
4. Relevance of all concepts	0.8	4	1	3
5. Value for knowledge translation in RACFs	0.8	4	1	3
6. Flexible enough to be used in a variety of RACFs (transferability)	0.9	4	0.9	3
Ease of use
7. Language used is easy to understand (n = 10)	0.7	3	0.9	3
8. A simplistic guide (round 1)/clear guide (round 2) for knowledge translation in RACFs	0.9	3	0.9	3

Abbreviation: RACFs, Residential aged care facilities.

In the first e‐Delphi round, all items met the threshold of ≥ 0.8 agreement and a median of at least three, except for ‘language easy to understand’ (item 7). Feedback from narrative data guided the PAVE framework's refinement, analysed through colour‐coding and grouping of similar responses. These revisions informed the second Delphi round. The same standards applied for interpretation of the second round's results. In the second e‐Delphi round, all items met the threshold of ≥ 0.8 agreement and a median of at least three. Narrative feedback affirmed the PAVE validity but suggested potential for improving its usability for broader application through simplification. The PAVE framework is presented in Figure 4.

FIGURE 4.

The PAVE framework for wound care knowledge translation in residential aged care facilities.

The University Health Sciences Research Ethics Committee approved the study (UFS‐HSD2019/0600/2506‐0001). Informed consent was obtained from all participants.

3. Discussion

The PAVE framework is discussed, followed by the study limitations and implications.

3.1. Discussion of the PAVE Framework Contribution

The PAVE framework has four horizontal components: Process, Adoption process, Values and Engagement that extend from the left to the right across four phases, namely the pre‐implementation phase, the implementation phase, the evaluation phase and the sustainment phase (see Figure 4). The phases are indicated at the top of the PAVE framework illustration. The evaluation phase uniquely stipulates the outcomes for each horizontal component and represents both summative and continuous formative evaluation. These four phases are common to process models (Graham et al. 2006; Moullin et al. 2019) guiding the planning and execution of actions (Damschroder 2020).

Each of the four horizontal components delineates strategies for each knowledge translation phase, enhancing the framework's systematic approach for users. The strategies in the four components were aligned to an overarching mechanism of change (the NPT components) in the Adoption component. In the following sections, each horizontal component is explained progressively across the framework's four phases.

3.1.1. Process (The ‘P’ in PAVE)

The Process component offers steps and processes to progressively follow across the four phases of a knowledge translation project. Awareness‐raising and exploration of the problem are the two steps in the Process component to initiate the project. Although ‘exploration’ is common in process models, awareness‐raising has a unique position in the RACF where staff are seldom aware of new evidence. Evidence‐seeking behaviour is a barrier to evidence‐based practice in residential healthcare settings (Thiel et al. 2019).

The intervention to address the identified problem should be co‐designed. The co‐design process follows the sequence of a logic model. Suggesting a practice‐based approach, the evidence‐based and context‐specific sources that should continuously inform the intervention are shown in the framework across the phases, including knowledge of the available resources and legal parameters. A practice‐based approach is supported to ensure that actionable knowledge is created (West et al. 2019) and is aligned with an integrated knowledge translation approach (i‐KT). iKT refers to involving practitioners in all steps of the process (Canadian Institute of Health Research 2012), which is a valuable approach in RACFs owing to the need for democratising the team approach and building capacity for knowledge translation among nursing home staff (Keefe et al. 2020).

For the implementation phase, a cyclic process has been developed, referred to as the Monitoring Assessment Feedback and Adaptation (MAFA) cycle, that repeats itself until desired results are achieved or until summative evaluation. Although these strategies exist in the literature (Waltz et al. 2019), they have not yet been depicted in a single continuous cycle. As depicted in the evaluation column of the PAVE framework (Figure 4), both clinical and resident outcomes should be measured in addition to the implementation outcomes, which include the intervention's fidelity, adaptation and the cost of care. For sustainability, the MAFA cycles should be repeated to monitor the continued benefit and implementation of the intervention.

3.1.2. Adoption Process (The ‘A’ in PAVE)

The Adoption process component addresses actions that people collectively undertake as they engage with and embed the intervention in existing patterns, practices and knowledge (May et al. 2020). Constructs from the NPT of May et al. (2009, 2022) were adopted for this component because an implementation theory was not identified in the first phase of the study. The four constructs are coherence‐building (sense‐making), engagement (cognitive participation), collective action and reflexive monitoring (May et al. 2022). Workshop participants perceived reflexive monitoring, staff capacity‐building and intervention co‐design as critical during the continuous cycles of adaptation in the implementation phase. Colour‐coding was used to show the alignment between the Process component's pre‐implementation phase and the sense‐making construct and the alignment between the Engagement component and the ‘engagement and commitment’ construct in the PAVE framework.

3.1.3. Engagement and Team Development (The ‘E’ in PAVE)

The Engagement component concerns the behaviour change and the teambuilding that should occur throughout the project. Components of the Capability–Opportunity–Motivation–Behaviour (COM‐B) model (Michie et al. 2011) were adopted to explain individual behaviour change. In an RACF, care staff working in a team context are often required to change individual behaviour when a new evidence‐based practice is introduced. The components of the COM‐B model can be used to guide planning efforts aimed at facilitating individual behaviour change. For instance, when introducing a new evidence‐based approach to managing skin tears, RACF staff should receive training to ensure they possess the necessary knowledge and skills (Capability); there are residents that require the care (Opportunity) and staff could be motivated by demonstrating that the new intervention leads to faster healing, reduced pain for the older person and saves costs (Motivation).

A new ‘3C strategy’ (Core team–Consultation–Continuous agreement) was developed to explain flexible teambuilding. This entails: (1) the establishment of a Core team with at least the nurse manager and an implementation support practitioner or researcher, (2) Consultation and partnerships with experts (typically healthcare professionals who need to be involved for an evidence‐based approach) and (3) Continuous agreement discussions with all the implementers to ensure engagement and commitment for effective teamwork. Blended facilitation supports the gradual transition of ownership from the researcher to the implementers to ensure full ownership (as one of the outcomes) and the potential for sustainment at the end of a project.

3.1.4. Fundamental Values (The ‘V’ in PAVE)

Fundamental Values provide a guide or compass for planning implementation or redirecting the focus when lost. Consideration of implementer values has only recently received attention in implementation research and could enhance the success of implementation and sustainment (Metz et al. 2023). The fundamental values in the PAVE framework provide the underpinning for the knowledge translation change processes, ensuring that the dignity of residents is upheld with respectful and person‐centred care.

3.2. Limitations

The validity of the framework is based on expert consensus opinion. Future studies can examine the PAVE framework's performance in different RACFs using quantitative and qualitative methods. The PAVE framework is complex and can be refined or simplified for wider use in RACFs globally and in other healthcare contexts. A plain language summary of the PAVE framework is included in Appendix S2.

3.3. Implications

The PAVE framework provides a comprehensive and systematic tool that guides decision‐making for implementation work in RACFs based on fundamental values for holistic and dignified care. Although several implementation frameworks and process models exist and some have been used in the RACF context (Damschroder 2020; Lavallée et al. 2018; Harnett et al. 2020; Mekki et al. 2017), the PAVE framework is the first comprehensive and theory‐based framework to guide the entire implementation process specific to wound care in the RACF context. The PAVE framework addresses the need to guide the complexity of knowledge translation in RACFs (Basinska et al. 2022; Levine et al. 2021) and can be used by gerontology nurses, researchers, policymakers and educators.

An advantage of the framework's comprehensiveness is that users, particularly healthcare professionals, including gerontology nurses, educators and those less familiar with implementation science, do not need to consult multiple separate frameworks to guide the implementation process. Educators could use the PAVE framework to facilitate the learning of knowledge translation processes in healthcare settings. However, one exception to the comprehensiveness of the PAVE framework is the need for a determinant framework to assess contextual barriers and facilitators such as the Consolidated Framework for Implementation Research (CFIR) (Damschroder et al. 2022). The CFIR may be used alongside the PAVE framework, as its constructs can be adapted to specific implementation contexts. Moreover, the CFIR is publicly accessible via its website (https://cfirguide.org/constructs/).

A further advantage of the PAVE framework is the option to use the framework components separately. For example, the fundamental values could be used to explore the value system of stakeholders in a new project or the 3C strategy could be used to guide team development. The 3C strategy is an original theoretical contribution providing a structure for developing teams to implement work related to wound care in RACFs. A specific structure for team development is necessary since evidence‐based wound care requires an interprofessional approach (Heerschap et al. 2019; Sherman and Kamel 2019) and implementation requires a team approach for co‐design and facilitation of change (Kittelman et al. 2021; Rolland et al. 2021), especially in the RACF context where insight into research and implementation is limited among staff members.

The PAVE framework can be used to plan knowledge translation projects in RACFs, to retrospectively analyse projects, or it can be used in other research works including realist reviews. The PAVE framework is grounded in the theory of NPT and outlines several relationships that can help implementation scientists, researchers and practitioners to explain the successes and challenges of implementation efforts. Theoretical approaches are necessary to enhance the probability of sustained change (Birken et al. 2018; Damschroder 2020), while explaining the failures can guide further improvements to embed evidence‐based wound care in daily practice. Integration of the fundamental values in the PAVE framework is a unique contribution which could increase the probability of sustained implementation and bridge the gap in the lack of implementation strategy alignment with values (Metz et al. 2023). Ultimately, the use of the PAVE framework aims to guide the translation of evidence‐based practices into daily care in RACFs to improve wound outcomes while maintaining the dignity of older people at risk of or with a wound. The use of the PAVE framework across a variety of RACFs may facilitate the identification of common successes in practice change, which can inform the development of policies relevant to real‐world contexts.

Adaptation of the PAVE framework to various RACF and healthcare contexts is possible since the four core components in the PAVE framework are underpinned by generic principles. For example, the Process component's pre‐implementation steps may be applied non‐linearly or iteratively, depending on the needs of a particular context. The Engagement component's principles underpinning the development of implementation teams, captured in the 3C strategy, are broadly applicable. However, the specific composition of implementation teams may vary, especially in low‐resource or developing countries where implementation support practitioners or healthcare specialists may not be readily available. In such cases, the principle of expert consultation remains applicable, although innovative methods such as telehealth consultations may be necessary to access appropriate expertise. Furthermore, while the PAVE framework embeds a set of foundational values applicable to wound care in RACFs, it is recommended that each project conduct a value clarification and replace the PAVE framework's values with the identified priority stakeholder values that are locally meaningful and culturally appropriate. Such adaptations to the PAVE framework can enhance the relevance, acceptability and sustainability of implementation efforts. To support ongoing contextual adaptation, future research should report on how the PAVE framework is operationalised in diverse settings.

4. Conclusion

To ensure dignified holistic quality care for older people, integrating evidence‐based wound care practices into RACFs' daily routines is essential. This study contributed methodologically, describing the multi‐phase development process of the PAVE framework tailored to a healthcare context. The PAVE framework is a theoretical contribution and the first comprehensive framework to guide knowledge translation in RACFs. While designed for South African RACFs, the framework is applicable across various international settings. Experts view the PAVE framework as comprehensive and suitable for guiding gerontology nurses, researchers and implementation support practitioners in systematic planning or retrospective analysis of knowledge translation projects in RACFs. The PAVE framework's emphasis on engagement, collaboration and value integration can enhance change efficiency and sustainability. Ultimately, the use of the PAVE framework can assist gerontology nurses and researchers to systematically improve care for older people and their quality of life through knowledge translation.

Author Contributions

This article is based on the author's thesis entitled ‘A framework for wound care knowledge translation in residential aged care facilities’ towards the degree of Doctor of Philosophy in Nursing in the School of Nursing, Faculty of Health Sciences, University of the Free State. Geertien Christelle Boersema was the PhD candidate and principal investigator supervised by Prof Yvonne Botma and Prof Magda Mulder. The manuscript was conceptualised and approved by all three authors.

Ethics Statement

The study was approved by the University of the Free State Health Sciences Research Ethics Committee. All participants signed informed consent.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: Review 1 search strategy.

Table S2: Review 1, appraisal of models and frameworks for usability, testability, applicability, and acceptability according to the Theory Comparison and Selection Tool (T‐CaST).

Table S3: Characteristics of the review 1 included studies, reports, models, and frameworks.

Table S4: Review 2 search strategy.

Table S5: Systematic review 2, quality appraisal for studies according to the Johns Hopkins Nursing Evidence‐Based Practice Research Evidence Appraisal Tool.

Table S6: Characteristics of the review 2 included primary studies.

Figure S1: The clinical wound care workflow conceptual model.

Appendix S2: A plain language summary of the PAVE framework.

Boersema, G. C. , Botma Y., and Mulder M.. 2025. “Improving Wound Care in Residential Aged Care Facilities: Development, Validation and Use of a Novel Knowledge Translation Framework.” International Journal of Older People Nursing 20, no. 5: e70044. 10.1111/opn.70044.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.