Research Article: Validating the Alberta Context Tool in a multi-site Australian Emergency Department nurse population

Date Published: April 9, 2019

Publisher: Public Library of Science

Author(s): Verena Schadewaldt, Benjamin McElduff, Catherine D’Este, Elizabeth McInnes, Simeon Dale, Anoja Gunaratne, Janet Squires, Dominique A. Cadilhac, Sandy Middleton, Liza Heslop.


The organisational context of healthcare settings has an essential role in how research evidence is used in clinical practice. The Alberta Context Tool (ACT) measures 10 concepts of organisational context with higher scores indicating a more positive work environment and potentially better use of research evidence in patient care. We assessed the psychometric properties of the ACT in Emergency Departments (EDs). This validation study was conducted as part of a multi-centre trial of triage, treatment and transfer (T3 Trial) of patients with stroke admitted to EDs. Stratified sampling with proportional allocation was used to recruit ED nurses from 26 participating hospitals at baseline. Nurses completed a survey containing the ACT. Structural validity was investigated by exploratory and confirmatory factor analysis. Reliability was assessed using Cronbach’s alpha and intraclass correlation coefficients. Item-rest correlations and the average inter-item correlations were also assessed. 558 ED nurses completed the survey, comprised of 433 surveys without missing data. Our exploratory factor analysis produced a 14-factor structure, explaining 62% of variance of organisational context. For eight of ten concepts, item loadings matched the factor structure of the original ACT. Confirmatory factor analysis of the 10 ACT concepts showed moderate model fit (p = 0.001, root mean square error of approximation: 0.049, standardised root mean squared residual: 0.048). Cronbach’s alphas showed very good internal consistency for nine of ten ACT concepts (α>0.7; 0.45–0.90). Item-rest correlations indicated that most ACT items (50 of 56 items) within any concept related well to the total score of the concept. Average inter-item correlations indicated potential redundant items for three concepts (feedback processes, leadership, staffing) that were above the threshold of 0.5. While identifying a few shortcomings for some ACT concepts in an ED context, the majority of findings confirm reliability and validity of the original ACT in an Australian population of ED nurses.

Partial Text

Implementing research findings into clinical practice is crucial to provide high quality care. However, researchers and clinicians struggle to achieve and sustain the translational process from evidence into practice despite available implementation strategies [1–3]. Implementation research has identified context as influential in terms of health professionals’ research utilisation [4–7] and the implementation and dissemination process of research-based knowledge in a clinical setting [8]. ‘Context’ refers to a number of human factors such as leadership, staff interaction and staffing levels and also structural factors such as workplace culture, available resources and physical work space [9]. In this paper we refer to context as ‘organisational context’ of a health care setting comprising all of the above factors. Evidence is growing that supports that the use of research to inform practice is greatest in those settings with positive perceptions by staff of their workplace context [10–12]. Conducting an assessment of organisational context can identify those factors that may impact upon whether or not evidence-based resources such as clinical practice guidelines will be used by clinical staff [11]. Staff are then enabled to address the modifiable factors of organisational context, thus helping to provide the optimum environment for the introduction of evidence based practice [13].

This validation study in a large sample of 558 ED nurses from 26 Australian hospitals confirms the structural validity and reliability of the ACT to assess organisational context within this setting. That means, the ACT can be applied in an ED setting to evaluate the structural and human factors that may impact on the use of research evidence by nurses. Reliability as well as validity measures met the standards for good scale quality for almost all items within the scale. We achieved a high number of returned surveys, further adding to the strength of these findings.

Findings of our validation study in Australian ED settings provide evidence for the feasibility, validity and reliability of the ACT. While some conceptual shortcomings for individual concepts were detected, these can generally be explained by the tool developers’ choice of concept and item construction. Other limitations may be related to the application of the ACT in an ED environment. The ACT was developed based on data from nurses in nursing homes and non-acute wards and some items to assess context do not relate well to the specific high-acuity work context of EDs. While our validity and reliability analysis predominantly showed good results for the ACT in an ED nurse population, an amended ACT version for the ED environment may yield even better results.