Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes

Pre-implementation planning for a sepsis intervention in a large learning health system: a qualitative study

BACKGROUND

Sepsis survivors experience high morbidity and mortality. Though recommended best practices have been established to address the transition and early post hospital needs and promote recovery for sepsis survivors, few patients receive recommended post-sepsis care. Our team developed the Sepsis Transition and Recovery (STAR) program, a multicomponent transition intervention that leverages virtually-connected nurses to coordinate the application of evidence-based recommendations for post-sepsis care with additional clinical support from hospitalist and primary care physicians. In this paper, we present findings from a qualitative pre-implementation study, guided by the Consolidated Framework for Implementation Research (CFIR), of factors to inform successful STAR implementation at a large learning health system prior to effectiveness testing as part of a Type I Hybrid trial.

METHODS

We conducted semi-structured qualitative interviews (n = 16) with 8 administrative leaders and 8 clinicians. Interviews were transcribed and analyzed in ATLAS.ti using a combination deductive/inductive strategy based on CFIR domains and constructs and the Constant Comparison Method.

RESULTS

Six facilitators and five implementation barriers were identified spanning all five CFIR domains (Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals and Process). Facilitators of STAR included alignment with health system goals, fostering stakeholder engagement, sharing STAR outcomes data, good communication between STAR navigators and patient care teams/PCPs, clinician promotion of STAR with patients, and good rapport and effective communication between STAR navigators and patients, caregivers, and family members. Barriers of STAR included competing demands for staff time and resources, insufficient communication and education of STAR's value and effectiveness, underlying informational and technology gaps among patients, lack of patient access to community resources, and patient distrust of the program and/or health care.

CONCLUSIONS

CFIR proved to be a robust framework for examining facilitators and barriers for pre-implementation planning of post-sepsis care programs within diverse hospital and community settings in a large LHS. Conducting a structured pre-implementation evaluation helps researchers design with implementation in mind prior to effectiveness studies and should be considered a key component of Type I hybrid trials when feasible.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04495946 . Registered August 3, 2020.

Stimulating implementation of clinical practice guidelines in hospital care from a central guideline organization perspective: A systematic review

BACKGROUND

The uptake of guidelines in care is inconsistent. This review focuses on guideline implementation strategies used by guideline organizations (governmental agencies, scientific/professional societies and other umbrella organizations), experienced implementation barriers and facilitators and impact of their implementation efforts.

METHODS

We searched PUBMED, EMBASE and CINAHL and conducted snowballing. Eligibility criteria included guidelines focused on hospital care and OECD countries. Study quality was assessed using the Mixed Methods Appraisal Tool. We used framework analysis, narrative synthesis and summary statistics.

RESULTS

Twenty-six articles were included. Sixty-two implementation strategies were reported, used in different combinations and ranged between 1 and 16 strategies per initiative. Most frequently reported strategies were educational session(s) and implementation supporting materials. The most commonly reported barrier and facilitator were respectively insufficient healthcare professionals' time and resources; and guideline's credibility, evidence base and relevance. Eighty-five percent of initiatives that measured impact achieved improvements in adoption, knowledge, behavior and/or clinical outcomes. No clear optimal approach for improving guideline uptake and impact was found. However, we found indications that employing multiple active implementation strategies and involving external organizations and hospital staff were associated with improvements.

CONCLUSION

Guideline organizations employ diverse implementation strategies and encounter multiple barriers and facilitators. Our study uncovered potential effective implementation practices. However, further research is needed on effective tailoring of implementation approaches to increase uptake and impact of guidelines.

MyBack - effectiveness and implementation of a behavior change informed exercise programme to prevent low back pain recurrences: a hybrid effectiveness-implementation randomized controlled study protocol

BACKGROUND

Low back pain (LBP) is a common health condition and the leading cause of years lived with disability worldwide. Most LBP episodes have a favourable prognosis, but recurrences within a year are common. Despite the individual and societal impact related to LBP recurrences, there is limited evidence on effective strategies for secondary prevention of LBP and successful implementation of intervention programmes in a real-world context. The aim of this study is to analyse the effectiveness of a tailored exercise and behavioural change programme (MyBack programme) in the secondary prevention of LBP; and evaluate acceptability, feasibility and determinants of implementation by the different stakeholders, as well as the implementation strategy of the MyBack programme in real context.

METHODS

This protocol describes a hybrid type I, randomized controlled trial to evaluate the effectiveness and implementation of MyBack programme in the context of primary health care. The Behaviour Change Wheel framework and FITT-VP principles will inform the development of the behaviour change and exercise component of MyBack programme, respectively. Patients who have recently recovered from an episode of non-specific LBP will be randomly assigned to MyBack and usual care group or usual care group. The primary outcome will be the risk of LBP recurrence. The secondary outcomes will include disability, pain intensity, musculoskeletal health, and health-related quality of life. Participants will be followed monthly for 1 year. Costs data related to health care use and the MyBack programme will be also collected. Implementation outcomes will be assessed in parallel with the effectiveness study using qualitative methods (focus groups with participants and health providers) and quantitative data (study enrolment and participation data; participants adherence).

DISCUSSION

To our knowledge, this is the first study assessing the effectiveness and implementation of a tailored exercise and behaviour change programme for prevention of LBP recurrences. Despite challenges related to hybrid design, it is expected that data on the effectiveness, cost-effectiveness, and implementation of the MyBack programme may contribute to improve health care in patients at risk of LBP recurrences, contributing to direct and indirect costs reduction for patients and the health system.

TRIAL REGISTRATION NUMBER

NCT05841732.

"It's more than just a conversation about the heart": exploring barriers, enablers, and opportunities for improving the delivery and uptake of cardiac neurodevelopmental follow-up care

Introduction

Surveillance, screening, and evaluation for neurodevelopmental delays is a pivotal component of post-surgical care for children with congenital heart disease (CHD). However, challenges exist in implementing such neurodevelopmental follow-up care in international practice. This study aimed to characterise key barriers, enablers, and opportunities for implementing and delivering outpatient cardiac neurodevelopmental follow-up care in Australia.

Methods

an exploratory descriptive qualitative study was conducted with healthcare professionals across Australia who had lived experience of designing, implementing, or delivering neurodevelopmental care for children with CHD. Online semi-structured interviews were conducted using a guide informed by the Consolidated Framework for Implementation Research to explore contextual influences. Interview transcripts were analysed using a rapid qualitative approach including templated summaries and hybrid deductive-inductive matrix analysis.

Results

fifty-two participants were interviewed. Perceived barriers and enablers were organised into six higher-order themes: factors in the broader environmental, economic, and political context; healthcare system factors; organisational-level factors; provider factors; patient and family factors; and care model factors. The largest number of barriers occurred at the healthcare system level (service accessibility, fragmentation, funding, workforce), while service providers demonstrated the most enabling factors (interprofessional relationships, skilled teams, personal characteristics). Strategies to improve practice included building partnerships; generating evidence; increasing funding; adapting for family-centred care; and integrating systems and data.

Discussion

Australia shares many similar barriers and enablers to cardiac neurodevelopmental care with other international contexts. However, due to unique geographical and health-system factors, care models and implementation strategies will require adaption to the local context to improve service provision.

Effectiveness of a classification-based approach to low back pain in primary care - a benchmarking controlled trial

OBJECTIVE

The aim of this study was to assess the effectiveness of classification-based approach for low back pain care in Finnish primary care.

DESIGN

A benchmarking controlled trial design was used.

SUBJECTS/PATIENTS

Three primary healthcare areas and 654 low back pain patients with or without sciatica.

METHODS

Classification-based care (using the STarT Back Tool) was implemented using organizational-, healthcare professional-, and patient-level interventions. The primary outcome was change in Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF-20) from baseline to 12 months.

RESULTS

No difference was found between the intervention and control in change in PROMIS PF-20 over the 12-month follow-up (mean difference 0.33 confidence interval -2.27 to 2.9, p = 0.473). Low back pain-related healthcare use, imaging, and sick leave days were significantly lower in the intervention group. Reduction in intensity of low back pain appeared to be already achieved at the 3-month follow-up (mean difference -1.3, confidence interval -2.1 to -0.5) in the intervention group, while in the control group the same level of reduction was observed at 12 months (mean difference 0.7, confidence interval -0.2 to 1.5, treatment*time p = 0.003).  Conclusion: Although classification-based care did not appear to influence physical functioning, more rapid reductions in pain intensity and reductions in healthcare use and sick leave days were observed in the intervention group.

Understanding factors that influence goal setting in rehabilitation for paediatric acquired brain injury: a qualitative study using the Theoretical Domains Framework

Background While goal setting with children and their families is considered best practice during rehabilitation following acquired brain injury, its successful implementation in an interdisciplinary team is not straightforward. This paper describes the application of a theoretical framework to understand factors influencing goal setting with children and their families in a large interdisciplinary rehabilitation team. Methods A semi-structured focus group was conducted with rehabilitation clinicians and those with lived experience of paediatric acquired brain injury (ABI). The 90-min focus group was audio-recorded and transcribed verbatim. Data were thematically coded and mapped against the Theoretical Domains Framework (TDF) to understand influencing factors, which were then linked to the Capability, Opportunity, Motivation - Behaviour (COM-B) model. Results A total of 11 participants (nine paediatric rehabilitation clinicians, one parent and one young person with lived experience of paediatric ABI) participated in the focus group. Factors influencing collaborative goal setting mapped to the COM-B and six domains of the TDF: Capabilities (Skills, Knowledge, Beliefs about capabilities, and Behavioural regulation), Opportunities (Environmental context and resources), and Motivation (Social/professional role and identity). Results suggest that a multifaceted intervention is needed to enhance rehabilitation clinicians' and families' skills and knowledge of goal setting, restructure the goal communication processes, and clarify the roles clinicians play in goal setting within the interdisciplinary team. Conclusion The use of the TDF and COM-B enabled a systematic approach to understanding the factors influencing goal setting for children with acquired brain injury in a large interdisciplinary rehabilitation team, and develop a targeted, multifaceted intervention for clinical use. These represent important considerations for the improvement of collaborative goal setting in paediatric rehabilitation services to ensure that best practice approaches to goal setting are implemented effectively in clinical practice.

Mis-implementation of evidence-based behavioural health practices in primary care: lessons from randomised trials in Federally Qualified Health Centers

Background

Implementing evidence-based practices (EBPs) within service systems is critical to population-level health improvements - but also challenging, especially for complex behavioral health interventions in low-resource settings. "Mis-implementation" refers to poor outcomes from an EBP implementation effort; mis-implementation outcomes are an important, but largely untapped, source of information about how to improve knowledge exchange.

Aims and objectives

We present mis-implementation cases from three pragmatic trials of behavioral health EBPs in U.S. Federally Qualified Health Centers (FQHCs).

Methods

We adapted the Consolidated Framework for Implementation Research and its Outcomes Addendum into a framework for mis-implementation and used it to structure the case summaries with information about the EBP and trial, mis-implementation outcomes, and associated determinants (barriers and facilitators). We compared the three cases to identify shared and unique mis-implementation factors.

Findings

Across cases, there was limited adoption and fidelity to the interventions, which led to eventual discontinuation. Barriers contributing to mis-implementation included intervention complexity, low buy-in from overburdened providers, lack of alignment between providers and leadership, and COVID-19-related stressors. Mis-implementation occurred earlier in cases that experienced both patient- and provider-level barriers, and that were conducted during the COVID-19 pandemic.

Discussion and conclusion

Multi-level determinants contributed to EBP mis-implementation in FQHCs, limiting the ability of these health systems to benefit from knowledge exchange. To minimize mis-implementation, knowledge exchange strategies should be designed around common, core barriers but also flexible enough to address a variety of site-specific contextual factors and should be tailored to relevant audiences such as providers, patients, and/or leadership.

Development of a goal-directed movement intervention (GOAL) using a movement sensor for hospitalized patients: An intervention mapping approach

OBJECTIVE

To describe the development of a goal-directed movement intervention in two medical wards, including recommendations for implementation and evaluation.

DESIGN

Implementation Research.

SETTING

Pulmonology and nephrology/gastroenterology wards of the University Medical Centre Utrecht, The Netherlands.

PARTICIPANTS

Seven focus groups were executed including 28 nurses, 7 physical therapists and 15 medical specialists. Patients' perceptions were repeatedly assessed during the iterative steps of the intervention development.

INTERVENTION

Interventions were targeted to each ward's specific character, following an Intervention Mapping approach using literature and research meetings. Main measures: Intervention components were linked to Behavior Change Techniques and implementation strategies will be selected using the Expert Recommendation Implementing Change tool. Evaluation outcomes like number of patients using the movement intervention will be measured, based on the taxonomy of Proctor.

RESULTS

The developed intervention consists of: insight in patients movement behavior (monitoring & feedback), goal setting (goals & planning) and adjustments to the environment (associations & antecedents). The following implementation strategies are recommended: to conduct educational meetings, prepare & identify champions and audit & provide feedback. To measure service and client outcomes, the mean level of physical activity per ward can be evaluated and the Net Promoter Score can be used.

CONCLUSION(S)

This study shows the development of a goal-directed movement intervention aligned with the needs of healthcare professionals. This resulted in an intervention consisting of feedback & monitoring of movement behavior, goal setting and adjustments in the environment. Using a step-by-step iterative implementation model to guide development and implementation is recommended.

Influences of specialty identity when implementing a new emergency department in Denmark: a qualitative study

BACKGROUND

The Danish Health Authority recommended the implementation of new types of emergency departments. Organizational changes in the hospital sector challenged the role, identity, and autonomy of medical specialists. They tend to identify with their specialty, which can challenge successful implementation of change. However, investigations on specialty identity are rare in implementation science, and how the co-existence of different specialty identities influences the implementation of new emergency departments needs to be explored for the development of tailored implementation strategies. The aim of this study was to examine how medical specialty identity influences collaboration between physicians when implementing a new emergency department in Denmark.

METHODS

Qualitative methods in the form of participants' observations at 13 oilcloth sessions (a micro-simulation method) were conducted followed up by 53 individual semi-structured interviews with participants from the oilcloth sessions. Out of the 53 interviews, 26 were conducted with specialists. Data from their interviews are included in this study. Data were analysed deductively inspired by Social Identity Theory.

RESULTS

The analysis yielded three overarching themes: [1] ongoing creation and re-creation of specialty identity through boundary drawing; [2] social categorization and power relations; and [3] the patient as a boundary object.

CONCLUSIONS

Specialty identity is an important determinant of collaboration among physicians when implementing a new emergency department. Specialty identity involves social categorization, which entails ongoing creation and re-creation of boundary drawing and exercising of power among the physicians. In some situations, the patient became a positive boundary object, increasing the possibility for a successful collaboration and supporting successful implementation, but direct expressions of boundaries and mistrust were evident. Both were manifested through a dominating power expressed through social categorization in the form of in- and out-groups and in an "us and them" discourse, which created distance and separation among physicians from different specialties. This distancing and separation became a barrier to the implementation of the new emergency department.

Physiotherapists' barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice in patients at risk of recurrence of low back pain: a qualitative study

BACKGROUND

Recurrences of low back pain (LBP) are frequent and associated with high levels of disability and medical costs. Regular exercise practice may be an effective strategy to prevent recurrences of LBP, however, the promotion of this behaviour by physiotherapists seems to be challenging. This study aims to explore physiotherapists' perceived barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice by patients at risk of recurrence of low back pain.

METHODS

Two focus groups with primary healthcare physiotherapists were conducted, based on a semi-structured interview schedule informed by the Behaviour Change Wheel, including the Capability, Opportunity, Motivation-Behaviour (COM-B) model and the Theoretical Domains Framework (TDF). All focus groups were held through videoconference, audio and video recorded and transcribed verbatim. A deductive content analysis, using a coding matrix based on the COM-B and TDF, was performed by two independent researchers. A third researcher was approached to settle disagreements.

RESULTS

In total, 14 physiotherapists participated in the focus groups. The analysis revealed a total of 13 barriers (4 COM-B components and 7 TDF domains) and 23 facilitators (5 COM-B and 13 TDF) to physiotherapists' implementation of a behaviour change-informed exercise intervention. The most common barriers were the lack of skills and confidence to implement the proposed intervention. These were explained by the fact that it differs from the usual practice of most participants and requires the learning of new skills applied to their contexts. However, for those who had already implemented other similar interventions or whose rationale is aligned with the new intervention, there seemed to exist more positive determinants, such as potential benefits for physiotherapists and the profession, improvement of quality of care and willingness to change clinical practice. For others who did not previously succeed in implementing these types of interventions, more context-related barriers were mentioned, such as lack of time to implement the intervention, schedule incompatibilities and lack of material and human resources.

CONCLUSIONS

This study identified modifiable barriers and facilitators to physiotherapists' implementation of a behaviour change-informed exercise intervention for patients at risk of recurrence of LBP in primary healthcare. The findings of this study will allow the systematic and theory-based development of a behaviour change-informed training programme, aimed at physiotherapists and supporting the successful implementation of the exercise intervention.

Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives

Machine learning (ML) solutions are increasingly entering healthcare. They are complex, sociotechnical systems that include data inputs, ML models, technical infrastructure and human interactions. They have promise for improving care across a wide range of clinical applications but if poorly implemented, they may disrupt clinical workflows, exacerbate inequities in care and harm patients. Many aspects of ML solutions are similar to other digital technologies, which have well-established approaches to implementation. However, ML applications present distinct implementation challenges, given that their predictions are often complex and difficult to understand, they can be influenced by biases in the data sets used to develop them, and their impacts on human behaviour are poorly understood. This manuscript summarises the current state of knowledge about implementing ML solutions in clinical care and offers practical guidance for implementation. We propose three overarching questions for potential users to consider when deploying ML solutions in clinical care: (1) Is a clinical or operational problem likely to be addressed by an ML solution? (2) How can an ML solution be evaluated to determine its readiness for deployment? (3) How can an ML solution be deployed and maintained optimally? The Quality Improvement community has an essential role to play in ensuring that ML solutions are translated into clinical practice safely, effectively, and ethically.

Buprenorphine misinformation and willingness to treat patients with opioid use disorder among primary care-aligned health care professionals

BACKGROUND

Buprenorphine is a highly effective medication for opioid use disorder that is underused by health care professionals (HCPs). Medications for opioid use disorder (MOUD) misinformation may be an important barrier to buprenorphine access, but most implementation strategies have aimed to reduce negative attitudes towards patients with opioid use disorder (OUD) rather than misinformation specific to buprenorphine use. In this study, we assessed the degree to which HCPs endorsed misinformation related to buprenorphine, and whether this is associated with willingness to provide care to patients with OUD.

METHODS

In September-December of 2022, we surveyed HCPs practicing in Ohio (n = 409). Our primary outcomes included a previously validated 5-item measure of HCP willingness to treat patients with OUD, and three other measures of willingness. Our key independent variable was a study-developed 5-item measure of endorsement of misinformation related to buprenorphine, which assessed beliefs in buprenorphine's efficacy in managing withdrawal symptoms and reducing overdose deaths as well as beliefs about the role of buprenorphine in achieving remission. We computed descriptive and bivariable statistics and fit regression models predicting each outcome of interest.

RESULTS

On average, HCPs scored 2.34 out of 5.00 (SD = 0.80) on the composite measure of buprenorphine misinformation. 48.41% of participants endorsed at least one piece of misinformation. The most endorsed items were that buprenorphine is ineffective at reducing overdose deaths (M = 2.75, SD =0 .98), and that its use substitutes one drug for another (M = 2.41, SD = 1.25). HCP endorsement of buprenorphine misinformation significantly and negatively predicted willingness to work with patients with OUD (b = - 0.34; 95% CI - 0.46, - 0.21); intentions to increase time spent with this patient population (b = - 0.36; 95% CI - 5.86, - 1.28); receipt of an X-waiver (OR = 0.54, 95% CI 0.38, 0.77); and intention to get an X-waiver (OR: 0.56; 95% CI: 0.33-0.94).

CONCLUSIONS

Misinformation is common among HCPs and associated with lower willingness to treat patients with OUD. Implementation strategies to increase MOUD use among HCPs should specifically counter misinformation related to buprenorphine.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT05505227. Registered 17 August 2022, https://clinicaltrials.gov/ct2/show/NCT05505227.

Screening and management of osteoporosis: a survey of knowledge, attitude, and practice among healthcare professionals in Egypt-a study by the Egyptian Academy of Bone Health

Secondary-level healthcare professionals, mainly rheumatologists and orthopedic surgeons, were invited to participate in an online survey questionnaire to assess knowledge and compliance with osteoporosis management guidelines and strategies, as well as self-reported quality of care. About 51% of the participants admit that they do not implement specific guidelines for the management of osteoporosis in their standard practice and depend on their experience and their clinical judgments. Moreover, although a good percentage (58%) had satisfactory knowledge levels in domains on the risk of osteoporotic fractures and investigations of osteoporosis, 47.5% of the participants did not score satisfactorily in questions on pharmacotherapy, especially for those patients at high risk for fractures.

INTRODUCTION

A recently published study demonstrated a treatment gap among those eligible for osteoporosis therapy in Egypt of about 82.1% in postmenopausal women and 100% in men. The current survey aimed to address some of the factors that may contribute to this wide gap.

METHODS

This was a cross-sectional study of secondary care healthcare professionals (both physicians and orthopedic surgeons) who were invited to complete an online questionnaire, which gathered information about physicians' socio-demographic data, knowledge, and compliance with osteoporosis management guidelines and strategies, as well as self-reported quality of care. Additionally, a knowledge score was calculated for all the participants.

RESULTS

A good percentage (58%) had a satisfactory knowledge level in domains on the risk of osteoporotic fractures and investigations of osteoporosis; however, 47.5% did not score satisfactorily in questions on pharmacotherapy, especially for those patients at high risk for fractures.

CONCLUSIONS

This work has identified some of the barriers to implementing guidelines for osteoporosis and fragility fracture management. In the meantime, it highlights the urgency of intensifying efforts to develop the knowledge and attitude of the healthcare professionals dealing with this condition in Egypt.

An iterative approach to developing a multifaceted implementation strategy for a complex eHealth intervention within clinical practice

BACKGROUND

The number of complex eHealth interventions has increased considerably. Despite available implementation theory outlining well-designed strategies, implementing complex interventions within practice proves challenging and often does not lead to sustainable use. To improve sustainability, theory and practice should be addressed during the development of an implementation strategy. By subsequently transparently reporting the executed theory-based steps and their corresponding practice findings, others can learn from these valuable lessons learned. This study outlines the iterative approach by which a multifaceted implementation strategy for a complex eHealth intervention in clinical practice was developed, tested and refined.

METHODS

We implemented the BENEFIT program, an advanced eHealth platform with Personal Health Portal facilitating healthy living in cardiac patients. In six iterative phases alternating between theory and practice, the implementation strategy was developed, tested and refined. The initial implementation strategy (phase 1) was drawn up using the Implementation model and RE-AIM. Subsequently, this strategy was further updated in brainstorming sessions and group discussions with twenty key stakeholders from three cardiac care centres and then evaluated in a pilot (phases 2 and 3).

RESULTS

The pilot of the program led to the identification of (context-specific) key challenges in practice (phase 4), which were subsequently connected back to broader theory (phase 5) using the Consolidated Framework of Implementation Research (CFIR). In the final phase, practice recommendations tackling the key challenges were formulated (phase 6) based on CFIR theory, the CFIR-ERIC Matching Tool, and stakeholders' input and feedback. These recommendations were then added to the refined strategy. Thus, executing this approach led to the realisation and use of a multifaceted theory-informed practice-based implementation strategy.

CONCLUSION

This case study gives an in-depth description of an iterative approach to developing an evidence-based, practice-tailored strategy for implementing a complex eHealth intervention in cardiac care. As such, this study may serve as a blueprint for other researchers aspiring to implement complex eHealth interventions within clinical practice sustainably.

From pilot to a multi-site trial: refining the Early Detection of Deterioration in Elderly Residents (EDDIE +) intervention

BACKGROUND

Early Detection of Deterioration in Elderly Residents (EDDIE +) is a multi-modal intervention focused on empowering nursing and personal care workers to identify and proactively manage deterioration of residents living in residential aged care (RAC) homes. Building on successful pilot trials conducted between 2014 and 2017, the intervention was refined for implementation in a stepped-wedge cluster randomised trial in 12 RAC homes from March 2021 to May 2022. We report the process used to transition from a small-scale pilot intervention to a multi-site intervention, detailing the intervention to enable future replication.

METHODS

The EDDIE + intervention used the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to guide the intervention development and refinement process. We conducted an environmental scan; multi-level context assessments; convened an intervention working group (IWG) to develop the program logic, conducted a sustainability assessment and deconstructed the intervention components into fixed and adaptable elements; and subsequently refined the intervention for trial.

RESULTS

The original EDDIE pilot intervention included four components: nurse and personal care worker education; decision support tools; diagnostic equipment; and facilitation and clinical support. Deconstructing the intervention into core components and what could be flexibly tailored to context was essential for refining the intervention and informing future implementation across multiple sites. Intervention elements considered unsustainable were updated and refined to enable their scalability. Refinements included: an enhanced educational component with a greater focus on personal care workers and interactive learning; decision support tools that were based on updated evidence; equipment that aligned with recipient needs and available organisational support; and updated facilitation model with local and external facilitation.

CONCLUSION

By using the i-PARIHS framework in the scale-up process, the EDDIE + intervention was tailored to fit the needs of intended recipients and contexts, enabling flexibility for local adaptation. The process of transitioning from a pilot to larger scale implementation in practice is vastly underreported yet vital for better development and implementation of multi-component interventions across multiple sites. We provide an example using an implementation framework and show it can be advantageous to researchers and health practitioners from pilot stage to refinement, through to larger scale implementation.

TRIAL REGISTRATION

The trial was prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020).

A Decision Tree Analysis on Symptom Experience of Asian American Breast Cancer Survivors

BACKGROUND

Mainly due to their cultural attitudes toward symptoms and breast cancer, Asian American breast cancer survivors tend to suffer from symptoms and often delay in getting treatments, information, and support. To improve their symptom management, it would be important to determine risk groups among them. Decision tree analyses reportedly help determine risk groups by identifying the characteristics that are directly associated with target health outcomes.

OBJECTIVE

Using a decision tree analysis, this study aimed at identifying the characteristics that were closely linked to the symptom experience of Asian American breast cancer survivors.

METHODS

This was a part of a parent randomized controlled trial among Asian American breast cancer survivors. Only the data from 135 women at the pre-test were included. Multiple instruments were used to collect the data: the Memorial Symptom Assessment Scale-Short Form, the Cancer Behavior Inventory, the PRQ-2000, the Perceived Isolation Scale, and the Supportive Care Needs Survey-Short Form 34. The data were analyzed using latent profile analysis and decision tree analyses.

RESULTS

Two most frequently found profiles included the low symptom experience profile (72.6%) and the high symptom experience profile (27.4%). The high symptom experience profile was predicted by 2 combined characteristics; (a) high psychological needs for help (over 60.00 points), and (b) low psychological needs for help (cut point = 60.00), high perceived barriers (cut point = 1.62), and high social isolation (social support) (cut point = 2.33).

CONCLUSIONS

These characteristics linked to Asian American breast cancer survivors with high symptom experience need to be considered in future intervention development.

Facilitators and barriers for using outdoor areas in the primary work tasks of eldercare workers in nursing homes

BACKGROUND

Eldercare workers in nursing homes report high musculoskeletal disorders, stressful work, and sickness absence. Initiatives that can accommodate these issues are needed. Current studies point out that nature contact may offer a range of human health benefits, potentially promoting healthier work among eldercare workers. Therefore, this study aimed to investigate facilitators and barriers for using outdoor areas as part of the daily work among eldercare workers in Danish nursing homes.

METHODS

In this multiple case study, we collected data from three nursing homes, conducting three semi-structured focus group interviews with eldercare workers and three individual interviews with nursing home managers. Furthermore, we conducted observations of the daily work and mappings of the nursing homes' outdoor environments to gain in-depth knowledge of eldercare workers' and managers' perspectives on using outdoor areas in their daily work. The data was thematically analysed using 'The Behaviour Change Wheel' (BCW), more specifically the COM-B model, as a theoretical foundation for exploring facilitators and barriers for the use of outdoor areas.

RESULTS

Frequently mentioned facilitators were facilities, traditions or repetitive events, positive experiences with residents ('star moments'), and knowledge about the residents. Frequently mentioned barriers were insufficient staffing, hierarchy in the work tasks, professional identity, and lack of ideas.

CONCLUSIONS

The identified facilitators and barriers should be considered when designing initiatives for increased use of outdoor areas or activities of eldercare workers.

TRIAL REGISTRATION

According to the Danish ethics committee (Law of committee, (komitéloven) paragraph 14, Sect. 2), qualitative interviews, which do not include human biological materials, do not need neither approval by ethical and scientific committee or informed consent (The Danish National Centre for Ethics).

Guideline-Adherent Physiotherapy for Patients With Hip and Knee Osteoarthritis in Germany: Protocol for an Implementation Research Project Using the Theoretical Domains Framework and the Behavior Change Wheel

BACKGROUND

Hip and knee osteoarthritis is common and leads to pain, stiffness, and disability. Clinical practice guidelines provide recommendations based on the best available evidence to assist health care professionals and patients in clinical decision-making. However, several studies have reported a gap between guideline recommendations and clinical practice in physiotherapy. Improved implementation strategies and the removal of existing barriers may facilitate the transfer of evidence into clinical practice and contribute to optimized quality of care.

OBJECTIVE

This paper presents the protocol for a study that aims to describe the current physiotherapy practice in patients with hip and knee osteoarthritis and to investigate physiotherapists' adherence to clinical practice guidelines, to identify and specify barriers to and facilitators of guideline use and implementation, and to develop and pilot test a theory-based tailored implementation intervention aiming to increase guideline use in osteoarthritis care.

METHODS

The research project is divided into 4 parts. During the first part, we will conduct a nationwide web-based survey among German physiotherapists to evaluate the current management of hip and knee osteoarthritis and to evaluate whether treatment aligns with guideline recommendations. Subsequently, semistructured interviews will be conducted to specify barriers to and facilitators of guideline use and implementation among physiotherapists (part 2). On the basis of these findings, in part 3, we will develop a theory-driven implementation intervention based on the Theoretical Domains Framework and the Behavior Change Wheel, which will be evaluated in a controlled pilot study in terms of effectiveness, feasibility, and acceptability (part 4).

RESULTS

Data collection of the web-based survey among German physiotherapists (part 1) was completed in December 2021. The semistructured interviews (part 2) were conducted between January and September 2023. Recruitment of physiotherapy practices to participate in the development of the implementation intervention is expected to start in January 2024.

CONCLUSIONS

This research project aims to develop a theory-driven implementation intervention to facilitate the transfer of evidence from hip and knee osteoarthritis guidelines in physiotherapy practice. We hypothesize that successful implementation will lead to increased guideline adherence in physiotherapists, which in turn will improve the quality of care. The results from our project will provide valuable knowledge concerning the development process and effectiveness of tailored implementation interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47834.

Revisiting the policy ecology framework for implementation of evidence-based practices in mental health settings

BACKGROUND

Over the past three decades, policy actors and actions have been highly influential in supporting the implementation of evidence-based practices (EBPs) in mental health settings. An early examination of these actions resulted in the Policy Ecology Framework (PEF), which was originally developed as a tactical primer for state and local mental health regulators in the field of child mental health. However, the policy landscape for implementation has evolved significantly since the original PEF was published. An interrogation of the strategies originally proposed in the PEF is necessary to provide an updated menu of strategies to improve our understanding of the mechanisms of policy action and promote system improvement.

OBJECTIVES

This paper builds upon the original PEF to address changes in the policy landscape for the implementation of mental health EBPs between 2009 and 2022. We review the current state of policy strategies that support the implementation of EBPs in mental health care and outline key areas for policy-oriented implementation research. Our review identifies policy strategies at federal, state, agency, and organizational levels, and highlights developments in the social context in which EBPs are implemented. Furthermore, our review is organized around some key changes that occurred across each PEF domain that span organizational, agency, political, and social contexts along with subdomains within each area.

DISCUSSION

We present an updated menu of policy strategies to support the implementation of EBPs in mental health settings. This updated menu of strategies considers the broad range of conceptual developments and changes in the policy landscape. These developments have occurred across the organizational, agency, political, and social contexts and are important for policymakers to consider in the context of supporting the implementation of EBPs. The updated PEF expands and enhances the specification of policy levers currently available, and identifies policy targets that are underdeveloped (e.g., de-implementation and sustainment) but are becoming visible opportunities for policy to support system improvement. The updated PEF clarifies current policy efforts within the field of implementation science in health to conceptualize and better operationalize the role of policy in the implementation of EBPs.

Implementation of interventions to maintain and promote the functional mobility of nursing home residents - a scoping review

BACKGROUND

To provide an overview of the available evidence on the implementation of direct and capacity-building interventions to promote and maintain the functional mobility of nursing home residents.

METHODS

We conducted a scoping review following the methodological guidance for the conduct of scoping reviews as described by the Joanna Briggs Institute. We searched for studies in MEDLINE (via PubMed) and CINAHL (via EBSCO). We conducted a qualitative content analysis of the included studies with deductive categories based on the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Ultimately, we included 8 studies on direct interventions, 6 studies on capacity-building interventions, and 2 studies on both types of interventions in our review. Seven studies provided evidence on implementation strategies comprising discrete as well as multifaceted, multilevel strategies. Most of the studies did not systematically evaluate the strategies but remained at a descriptive level. All 16 studies provided evidence of influencing factors. We identified 32 of the 37 influencing factors of the CFIR. The five most frequent influencing factors were available resources (n = 14), access to knowledge and information (n = 12), patient needs and resources (n = 10), knowledge and beliefs about the intervention (n = 10) and compatibility (n = 9).

CONCLUSIONS

The available evidence on the implementation of functional mobility interventions in nursing homes is rather limited. This emphasizes the need for further research. Regarding implementation strategies, the systematic evaluation and further development of the reported promising approaches might be a starting point.

Indicators to measure implementation and sustainability of nursing best practice guidelines: A mixed methods analysis

Background

The use of best practice guidelines (BPGs) has the potential to decrease the gap between best evidence and nursing and healthcare practices. We conducted an exploratory mixed method study to identify strategies, processes, and indicators relevant to the implementation and sustainability of two Registered Nurses' Association of Ontario (RNAO) BPGs at Best Practice Spotlight Organizations® (BPSOs).

Methods

Our study had four phases. In Phase 1, we triangulated two qualitative studies: a) secondary analysis of 126 narrative reports detailing implementation progress from 21 BPSOs spanning four sectors to identify strategies and processes used to support the implementation and sustainability of BPGs and b) interviews with 25 guideline implementers to identify additional strategies and processes. In Phase 2, we evaluated correlations between strategies and processes identified from the narrative reports and one process and one outcome indicator for each of the guideline. In Phase 3, the results from Phases 1 and 2 informed indicator development, led by an expert panel. In Phase 4, the indicators were assessed internally by RNAO staff and externally by Ontario Health Teams. A survey was used to validate proposed indicators to determine relevance, feasibility, readability, and usability with knowledge users and BPSO leaders.

Results

Triangulation of the two qualitative studies revealed 46 codes of implementation and sustainability of BPGs, classified into eight overarching themes: Stakeholder Engagement, Practice Interventions, Capacity Building, Evidence-Based Culture, Leadership, Evaluation & Monitoring, Communication, and Governance. A total of 28 structure, process, or outcome indicators were developed. End users and BPSO leaders were agreeable with the indicators according to the validation survey.

Conclusions

Many processes and strategies can influence the implementation and sustainability of BPGs at BPSOs. We have developed indicators that can help BPSOs promote evidence-informed practice implementation of BPGs.

The SITS framework: sustaining innovations in tertiary settings

Background

To date, little attention has focused on what the determinants are and how evidence-based practices (EBPs) are sustained in tertiary settings (i.e., acute care hospitals). Current literature reveals several frameworks designed for implementation of EBPs (0-2 years), yet fewer exist for the sustainment of EBPs (>2 years) in clinical practice. Frameworks containing both phases generally list few determinants for the sustained use phase, but rather state ongoing monitoring or evaluation is necessary. Notably, a recent review identified six constructs and related strategies that facilitate sustainment, however, the pairing of determinants and how best to sustain EBPs in tertiary settings over time remains unclear. The aim of this paper is to present an evidence-informed framework, which incorporates constructs, determinants, and knowledge translation interventions (KTIs) to guide implementation practitioners and researchers in the ongoing use of EBPs over time.

Methods

We combined the results of a systematic review and theory analysis of known sustainability frameworks/models/theories (F/M/Ts) with those from a case study using mixed methods that examined the ongoing use of an organization-wide pain EBP in a tertiary care center (hospital) in Canada. Data sources included peer-reviewed sustainability frameworks (n = 8) related to acute care, semi-structured interviews with nurses at the department (n = 3) and unit (n = 16) level, chart audits (n = 200), and document review (n = 29). We then compared unique framework components to the evolving literature and present main observations.

Results

We present the Sustaining Innovations in Tertiary Settings (SITS) framework which consists of 7 unique constructs, 49 determinants, and 29 related KTIs that influence the sustainability of EBPs in tertiary settings. Three determinants and 8 KTIs had a continuous influence during implementation and sustained use phases. Attention to the level of application and changing conditions over time affecting determinants is required for sustainment. Use of a participatory approach to engage users in designing remedial plans and linking KTIs to target behaviors that incrementally address low adherence rates promotes sustainability.

Conclusions

The SITS framework provides a novel resource to support future practice and research aimed at sustaining EBPs in tertiary settings and improving patient outcomes. Findings confirm the concept of sustainability is a "dynamic ongoing phase".

Development and Validation of COVID-19 Vaccine Messaging Materials for Latinx Communities

With pervasive health misinformation and mistrust, many of those at greatest risk from COVID-19 have demonstrated lower vaccine acceptance. In Chicago, IL, surveillance data has revealed lower rates of vaccine uptake among Black and Latinx individuals compared with others. We partnered with two local federally qualified health centers (FQHCs) to develop and implement language-concordant, low literacy patient education materials to promote COVID-19 vaccine knowledge, acceptance, and uptake. Our multi-phase study included: 1) iterative content generation and refinement by health literacy experts, health center providers and staff, and community-dwelling adults; and 2) materials testing via a two-arm randomized experiment among adults from Latinx communities in the Chicagoland area. Results indicate that our English and Spanish-language COVID-19 Fact Sheets increase knowledge about COVID-19 vaccination. These materials are publicly available and can be used by health centers or community organizations to promote COVID-19 vaccination among diverse populations.

An Evidence-Based Approach to Protecting Our Biggest Organ: Implementation of a Skin, Surface, Keep Moving, Incontinence/Moisture, and Nutrition/Hydration (SSKIN) Care Bundle

Background: The skin, surface, keep moving, incontinence/moisture, and nutrition/hydration (SSKIN) bundle is a resource to aid in care planning when at risk of pressure injuries. The bundle uses best practices to minimize variations in care. Objectives: The objectives of this quality improvement (QI) pilot project were as follows: (a) increase nurses' knowledge of pressure injury prevention, (b) increase nurses' knowledge of the use of the SSKIN bundle, and (c) to pilot the use of an SSKIN bundle in the clinical setting designed to standardize nursing interventions and documentation. Methods: Nurses completed a module on pressure injury prevention that included a pre- and posttest to determine knowledge. Education on the use of the SSKIN bundle was provided, followed by a posttest to establish understanding and knowledge gained. The bundle was utilized in the acute inpatient rehabilitation unit for 4 weeks, and compliance was assessed using the "all-or-none" approach (100% compliance). At the conclusion of the pilot project, staff nurses completed a post-survey created by the QI leader (Likert scale format). The survey included topics on the ease of learning to use the bundle, improved knowledge, perceived reduction in variation of care, perceived facilitation of discussion on skin, opinions on whether the bundle should be instituted hospital-wide, and incorporation of the bundle into the electronic health record (EHR). Results: There was an increase in pressure injury prevention knowledge from an average score of 88.89% on the pretest to 98.15% on the posttest. The mean score on the SSKIN bundle posttest was 93.75%. The bundle ran for 4 weeks and was initiated for ten patients during 74 shifts. Compliance with all components of the bundle was 77%. Conclusion: A pressure injury prevention initiative, such as the SSKIN bundle, can be a useful tool to help standardize nursing interventions and documentation. Implications for Nursing: Results revealed Nutrition as the component with the highest degree of noncompliance. Practice recommendations include documenting every patients nutrition information, regardless of Braden score.

Protocol for a hybrid II study exploring the feasibility of delivering, evaluating, and implementing a self-management programme for people with neuromuscular diseases at a specialist neuromuscular centre

BACKGROUND

Self-management support (SMS) forms a central pillar in the management of long-term conditions. It is firmly aligned with UK health policy but there is a paucity of evidence exploring how it is enacted in the context of neuromuscular diseases (NMDs). Bridges is a SMS programme originally developed in stroke. A new version of the programme (Neuromuscular Bridges) has recently been co-designed with people with lived experience of NMD and requires evaluation. The implementation of SMS is inherently complex with potential barriers at the level of the patient, provider, and wider organisation. The success of implementing programmes can be highly dependent on context, indicating a rationale for considering implementation determinants at an early stage. This study aims to explore the feasibility of (1) delivering, (2) evaluating, and (3) implementing Neuromuscular Bridges at a specialist neuromuscular centre.

METHODS

This study employs a hybrid II design underpinned by Normalisation Process Theory (NPT), which has been used prospectively to inform the implementation plan and will also inform the analysis. The feasibility of delivering, evaluating, and implementing Neuromuscular Bridges will be assessed using a single-arm pre-post design. In terms of delivery and evaluation, we will explore acceptability, demand within the service, performance of outcome measures, recruitment, and retention. Implementation strategies have been selected from a refined taxonomy of strategies, mapped to NPT, and targeted at known barriers and facilitators at the specialist centre that were identified from preliminary stakeholder engagement activities. The impact of the strategy bundle on fidelity, acceptability, appropriateness, and adoption will be evaluated using qualitative interviews, administrative data, surveys, and a notes audit.

CONCLUSIONS

This this study will provide valuable feasibility data on a co-designed SMS programme for people with NMDs that will be used to inform a larger implementation study, requirements for embedding it in a specialist centre, and rollout to other specialist centres. Using hybrid methodology at the feasibility stage is unusual and this study will provide important insights into the usefulness of taking this approach at this point in the research pipeline.

TRIAL REGISTRATION

ISRCTN Trial ID: ISRCTN14208138 . Date registered: 18/08/2021.

Tailoring an evidence-based clinical intervention and training package for the treatment and prevention of comorbid heavy drinking and depression in middle-income country settings: the development of the SCALA toolkit in Latin America

BACKGROUND

Effective interventions exist for heavy drinking and depression but to date there has been limited translation into routine practice in global health systems. This evidence-to-practice gap is particularly evident in low- and middle-income countries. The international SCALA project (Scale-up of Prevention and Management of Alcohol Use Disorders and Comorbid Depression in Latin America) sought to test the impact of multilevel implementation strategies on rates of primary health care-based measurement of alcohol consumption and identification of depression in Colombia, Mexico, and Peru.

OBJECTIVE

To describe the process of development and cultural adaptation of the clinical intervention and training package.

METHODS

We drew on Barrero and Castro's four-stage cultural adaption model: 1) information gathering, 2) preliminary adaption, 3) preliminary adaption tests, and 4) adaption refinement. The Tailored Implementation in Chronic Diseases checklist helped us identify potential factors that could affect implementation, with local stakeholder groups established to support the tailoring process, as per the Institute for Healthcare Improvement's Going to Scale Framework.

RESULTS

In Stage 1, international best practice guidelines for preventing heavy drinking and depression, and intelligence on the local implementation context, were synthesised to provide an outline clinical intervention and training package. In Stage 2, feedback was gathered from local stakeholders and materials refined accordingly. These materials were piloted with local trainers in Stage 3, leading to further refinements including developing additional tools to support delivery in busy primary care settings. Stage 4 comprised further adaptions in response to real-world implementation, a period that coincided with the onset of the COVID-19 pandemic, including translating the intervention and training package for online delivery, and higher priority for depression screening in the clinical pathway.

CONCLUSION

Our experience highlights the importance of meaningful engagement with local communities, alongside the need for continuous tailoring and adaptation, and collaborative decision-making.

Tailoring Implementation Strategies for Cardiovascular Disease Risk Calculator Adoption in Primary Care Clinics

INTRODUCTION

When implementing interventions in primary care, tailoring implementation strategies to practice barriers can be effective, but additional work is needed to understand how to best select these strategies. This study sought to identify clinicians' contributions to the process of tailoring implementation strategies to barriers in clinical settings.

METHODS

We conducted a modified nominal group exercise involving 8 implementation scientists and 26 primary care clinicians in the WWAMI region Practice and Research Network. Each group identified implementation strategies it felt would best address barriers to using a cardiovascular disease (CVD) risk calculator previously identified across 44 primary care clinics from the Healthy Hearts Northwest pragmatic trial (2015 to 2018). These barriers had been mapped beforehand to the Consolidated Framework for Implementation Research (CFIR) domains. We examined similarities and differences in the strategies that 30% or more of each group identified (agreed-on strategies) for each barrier and for barriers in each CFIR domain. We used the results to demonstrate how strategies might be tailored to individual clinics.

RESULTS

Clinicians selected 23 implementation strategies to address 1 or more of the 13 barriers; implementation scientists selected 35. The 2 groups agreed on at least 1 strategy for barriers in each CFIR domain: Inner Setting, Outer Setting, Intervention Characteristics, Characteristics of Individuals, and Process. Conducting local needs assessment and assessing for readiness/identifying barriers and facilitators were the 2 most common implementation strategies chosen only by clinicians.

CONCLUSIONS

Clinician stakeholders identified implementation strategies that augmented those chosen by implementation scientists, suggesting that codesign of implementation processes between implementation scientists and clinicians may strengthen the process of tailoring strategies to overcome implementation barriers.

Effects of an educational program using a virtual social network on nurses' knowledge and performance of blood pressure measurement: a randomized controlled trial

BACKGROUND

Hypertension diagnosis, treatment, and follow-up depend on accurate blood pressure measurement; however, inaccurate measurement techniques are common among healthcare providers. To improve professional performance, continuous education is necessary. Distance education through virtual social network can be used as it is easy to use and accessible.

METHODS

This study adopted a randomized controlled trial design and was conducted at two hospitals in Mansoura, Egypt. The subjects were selected from two hospitals using Stratified random sampling method in proportion to the total number of nurses. Seventy nurses were included in this study and were randomly divided into the intervention (n = 35) and control (n = 35) groups using block randomization. Data were gathered before and after intervention using a blood pressure measurement knowledge questionnaire and a blood pressure measurement observation checklist. The blood pressure measurement error (the difference between the BP determined by each observer and the reference BP) was calculated for the randomly selected recordings in both groups. The intervention group received 24 blood pressure measurement education sessions using WhatsApp, while the control group received only routine education using traditional lecture.

RESULTS

No statistically significant differences in pretest knowledge scores, performance scores, and range of error were found between both groups, whereas, after intervention, knowledge scores were higher in the intervention group than those in the control group (p < 0.001). The range of error of systolic and diastolic blood pressure values significantly reduced after the intervention in the intervention group, and the posttest performance scores were higher than the pretest performance scores; however, the difference was not statistically significant.

CONCLUSIONS

The blood pressure measurement education program via WhatsApp was effective in increasing nurses' knowledge and reducing the range of error; however, a multimodal approach may be required to improve performance scores.

TRIAL REGISTRATION

Prospectively registered with ClinicalTrials.gov on 09/03/2021; registration number NCT04789642.

Using Health Care Professionals' Perspectives to Refine a Clinical Decision Support Implementation Strategy for Increasing the Prescribing of HIV Preexposure Prophylaxis (PrEP) in Alabama

Pre-exposure prophylaxis (PrEP) is underused in the southern United States (US), a region with high HIV incidence. Clinical decision support (CDS) tools could increase PrEP prescriptions. We explored barriers to PrEP delivery and views of CDS tools to identify refinements for implementation strategies for PrEP prescribing and PrEP CDS tools. We conducted focus groups with health care providers from two federally qualified health centers in Alabama and analyzed the results using rapid qualitative methods. Barriers to PrEP included providers' lack of training in PrEP, competing priorities and time constraints during clinical visits, concerns about side effects, and intensive workload. We identified refinements to the planned implementation strategies to address the barriers, including training all clinic staff in PrEP and having CDS PrEP alerts in electronic health records sent to all staff. Development and deployment of CDS tools in collaboration with providers has potential to increase PrEP prescribing in high-priority jurisdictions.

Association between the number of adopted implementation strategies and contextual determinants: a mixed-methods study

BACKGROUND

The successful implementation of evidence-based innovations to improve healthcare delivery often requires a well-planned strategy to support their use. With a greater recognition of the importance of an implementation process, researchers have turned their attention to implementation strategies and their customization to target specific organizational barriers and facilitators. Further, there is a paucity of empirical evidence demonstrating the link between implementation determinants and the number of selected implementation strategies. The purpose of this mixed methods analysis is to examine how formatively assessed barriers and facilitators to implementation relate to the number and type of implementation strategies adopted to address context-specific factors.

METHODS

A mixed methods evaluation that included 15 rheumatology clinics throughout the United States that were planning for implementation of an evidence-based shared decision-making aid for patients with lupus. Quantitative data consisted of a count of the number of implementation strategies used by a clinic. Qualitative data collection was guided by the Consolidated Framework for Implementation Research (CFIR) and relied upon semi-structured interviews with 90 clinic members between November 2018 and August 2019.

RESULTS

Using the CFIR, we found that local clinic factors (Inner Setting Domain) resulted in different perceptions about Planning and Executing the DA (Process Domain); these domains were most likely to distinguish between the number and type of implementation strategies adopted by the clinics. In contrast, Intervention characteristics, Individual Characteristics, and the Outer Setting did not differentiate between the groups with different numbers of implementation strategies. The number and type of chosen strategies were not those associated with the context-specific factors.

CONCLUSIONS

Findings show that, despite recognition of the value of customizing implementation strategies for the contexts in which they are applied, they are too often chosen in a manner that fail to adequately reflect the diverse settings that may present unique factors associated with implementation. Our findings also highlight the importance of the inner context - both in terms of structural characteristics and existing work processes - as a driving factor for why some organizations select different numbers and types of implementation strategies.

Trends in guideline implementation: an updated scoping review

Background

Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review.

Methods

We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics.

Results

We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks (n=25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers (n=59) most often consulted literature (60%). Those that engaged stakeholders (n=42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions.

Conclusions

Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact.

Trial registration

The protocol was registered with Open Science Framework (https://osf.io/4nxpr) and published in JBI Evidence Synthesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01223-6.

Feasibility of a Reinforcement Learning-Enabled Digital Health Intervention to Promote Mammograms: Retrospective, Single-Arm, Observational Study

BACKGROUND

Preventive screenings such as mammograms promote health and detect disease. However, mammogram attendance lags clinical guidelines, with roughly one-quarter of women not completing their recommended mammograms. A scalable digital health intervention leveraging behavioral science and reinforcement learning and delivered via email was implemented in a US health system to promote uptake of recommended mammograms among patients who were 1 or more years overdue for the screening (ie, 2 or more years from last mammogram).

OBJECTIVE

The aim of this study was to establish the feasibility of a reinforcement learning-enabled mammography digital health intervention delivered via email. The research aims included understanding the intervention's reach and ability to elicit behavioral outcomes of scheduling and attending mammograms, as well as understanding reach and behavioral outcomes for women of different ages, races, educational attainment levels, and household incomes.

METHODS

The digital health intervention was implemented in a large Catholic health system in the Midwestern United States and targeted the system's existing patients who had not received a recommended mammogram in 2 or more years. From August 2020 to July 2022, 139,164 eligible women received behavioral science-based email messages assembled and delivered by a reinforcement learning model to encourage clinically recommended mammograms. Target outcome behaviors included scheduling and ultimately attending the mammogram appointment.

RESULTS

In total, 139,164 women received at least one intervention email during the study period, and 81.52% engaged with at least one email. Deliverability of emails exceeded 98%. Among message recipients, 24.99% scheduled mammograms and 22.02% attended mammograms (88.08% attendance rate among women who scheduled appointments). Results indicate no practical differences in the frequency at which people engage with the intervention or take action following a message based on their age, race, educational attainment, or household income, suggesting the intervention may equitably drive mammography across diverse populations.

CONCLUSIONS

The reinforcement learning-enabled email intervention is feasible to implement in a health system to engage patients who are overdue for their mammograms to schedule and attend a recommended screening. In this feasibility study, the intervention was associated with scheduling and attending mammograms for patients who were significantly overdue for recommended screening. Moreover, the intervention showed proportionate reach across demographic subpopulations. This suggests that the intervention may be effective at engaging patients of many different backgrounds who are overdue for screening. Future research will establish the effectiveness of this type of intervention compared to typical health system outreach to patients who have not had recommended screenings as well as identify ways to enhance its reach and impact.

Tracking, naming, specifying, and comparing implementation strategies for person-centred care in a real-world setting: a case study with seven embedded units

BACKGROUND

The implementation of person-centred care (PCC) is advocated worldwide. Stakeholders in charge of implementing PCC as a broad-scale change across the health care sector face two intertwined and complex challenges. First, making sense of PCC as an intervention with complex innovation characteristics and second, staging implementation of PCC by choosing appropriate implementation strategies. We aimed to explore one of these challenges by tracking, naming, specifying, and comparing which strategies and how strategies were enacted to support the implementation of more PCC in a real-world setting represented by one health care region in Sweden.

METHODS

A case study with seven embedded units at two organisational levels within a health care region was conducted from 2016 to 2019. Data were collected from three sources: activity logs, interviews, and written documents. Strategies were identified from all sources and triangulated deductively by name, definition, and cluster in line with the taxonomy Expert Recommendations for Implementing Change (ERIC) and specified according to recommendations by Proctor and colleagues as actor, action, action target, temporality, dose, outcome, and justification.

RESULTS

Four hundred thirteen activities were reported in logs, representing 43 discrete strategies identified in ERIC (n = 38), elsewhere (n = 1), or as emerging strategies (n = 4). The highest reported frequencies of discrete strategies were identified as belonging to two clusters: Train and educate stakeholders (40%) and Develop stakeholder interrelationships (38%). We identified a limited number of strategies belonging to the cluster Use evaluative and iterative strategies (4.6%) and an even smaller number of strategies targeting information to patients about the change initiative (0.8%). Most of the total dose of 11,076 person-hours in the 7 units was spent on strategies targeting health care professionals who provide PCC (81.5%) while the dose of strategies targeting support functions was 18.5%.

CONCLUSIONS

Our findings show both challenges and merits when strategies for implementation of PCC are conducted in a real-world setting. The results can be used to support and guide both scientists and practitioners in future implementation initiatives.

Evaluation of the nation-wide implementation of ALS home monitoring & coaching: an e-health innovation for personalized care for patients with motor neuron disease

BACKGROUND

To improve the care for patients with motor neuron disease an e-health innovation for continuous monitoring of disease progression and patients' well-being (ALS H&C) was implemented in 10 multidisciplinary rehabilitation settings. The first aim was to evaluate the implementation of ALS H&C by assessing several implementation outcomes, technology acceptance and usability of the innovation according to the end users. The secondary aim was to explore differences in these outcomes between the teams with sustainable and unsustainable implementation.

METHODS

The chosen implementation strategy was a combination of the implementation process model by Grol & Wensing and a participatory action research approach. In three meetings with multidisciplinary project groups the innovation was introduced, the expected barriers/facilitators identified, and action plans to resolve each barrier developed. After a 3-month pilot phase, patients and their healthcare providers were asked to complete an online evaluation survey to assess implementation outcomes, based on Proctor's evaluation framework (i.e., acceptability, feasibility, fidelity, sustainability). Telemedicine technology acceptance was assessed according the technology acceptance model of Chau, and user experiences with the System Usability Scale (SUS). Implementation outcomes of teams with sustainable implementation (continuation after completion of the pilot phase) and unsustainable implementation (discontinuation after the pilot phase) were compared.

RESULTS

The implementation outcomes from the patients' perspective (N = 71) were positive; they found ALS H&C to be an acceptable and feasible care concept. Patients' technology acceptance was high, with positive attitudes towards ALS H&C, and positive views on perceived technology control, usefulness, and ease of use. Patients rated their satisfaction with the (web) app on a scale from 1 (not satisfied at all) to 10 (very satisfied) with a 7.0 (median; IQR 1.0). Healthcare providers (N = 76) also found ALS H&C acceptable and appropriate as well, but were less positive about the feasibility and usability of ALS H&C (mean SUS 58.8 [SD 11.3]). ALS H&C has largely been implemented as intended and the implementation was sustainable in 7 teams. Teams who discontinued ALS H&C after the pilot phase (N = 2) had more fidelity issues.

CONCLUSIONS

A participatory action research approach supported by theoretical approaches used in implementation science led to a sustainable implementation of ALS H&C in 7 of the participating teams. To improve implementation success, additional implementation strategies to increase feasibility, usability and fidelity are necessary.

TRIAL REGISTRATION

Trial NL8542 registered at Netherlands Trial Register (trialregister.nl) on 15th April 2020.

Characterizing barriers to antibiotic stewardship for skin and soft-tissue infections in the emergency department using a systems engineering framework

OBJECTIVE

Skin and soft-tissue infections (SSTIs) account for 3% of all emergency department (ED) encounters and are frequently associated with inappropriate antibiotic prescribing. We characterized barriers and facilitators to optimal antibiotic use for SSTIs in the ED using a systems engineering framework and matched them with targeted stewardship interventions.

DESIGN AND PARTICIPANTS

We conducted semistructured interviews with a purposefully selected sample of emergency physicians.

METHODS

An interview guide was developed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Interviews were recorded, transcribed, and analyzed iteratively until conceptual saturation was achieved. Themes were identified using deductive directed content analysis guided by the SEIPS model.

RESULTS

We conducted 20 interviews with physicians of varying experience and from different practice settings. Identified barriers to optimal antibiotic prescribing for SSTIs included poor access to follow-up (organization), need for definitive diagnostic tools (tools and technology) and fear over adverse outcomes related to missed infections (person). Identified potential interventions included programs to enhance follow-up care; diagnostic aides (eg, rapid MRSA assays for purulent infections and surface thermal imaging for cellulitis); and shared decision-making tools.

CONCLUSIONS

Using a systems engineering informed qualitative approach, we successfully characterized barriers and developed targeted antibiotic stewardship interventions for SSTIs managed in the ED work system. The interventions span multiple components of the ED work system and should inform future efforts to improve antibiotic stewardship for SSTIs in this challenging care setting.

Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures: A Systematic Review

IMPORTANCE

Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient- and system-level factors.

OBJECTIVE

To catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS.

EVIDENCE REVIEW

A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components.

FINDINGS

Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements.

CONCLUSIONS AND RELEVANCE

In this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.

Current physical therapy practice and implementation factors regarding the evidence-based 'Rehabilitation of Mobility after Stroke (ReMoS)' guideline in Germany: a cross-sectional online survey

BACKGROUND

Evaluation of the current physical therapy practice for German stroke rehabilitation with respect to the 'Rehabilitation of Mobility after Stroke (ReMoS)' guideline recommendations and the associated implementation factors.

METHODS

A descriptive cross-sectional study employing an online survey was performed among German physical therapists in 2019. The survey consisted of three sections with open and closed questions: 1) self-reported use of ReMoS recommendations, 2) barriers of guideline use and 3) socio-demographic characteristics. The benchmark level for guideline adherent physical therapy was set at > 80%.

RESULTS

Data from 170 questionnaires were eligible for analysis. Participants' mean age was 41.6 years, 69.4% were female, while 60.1% had no academic degree. The ReMoS guideline was unknown to 52.9% of the responders. Out of all the 46 ReMoS guideline recommendations, only 'intensive walking training without a treadmill' was reported to be performed in a guideline adherent manner. Respondents usually denied any personal limitations, such as limited knowledge, or that the ReMoS guideline did not fit their routine practice.

CONCLUSIONS

Among German physical therapists, the ReMoS guideline is not well-known and many interventions are not performed as recommended, illustrating the discrepancies between the ReMoS guideline recommendations and current physical therapy practice. Interventions aimed at overcoming this gap should consider both knowledge of existing barriers and facilitators of guideline usage.

TRIAL REGISTRATION

The study was retrospectively registered to the German Clinical Trials Register ( DRKS00026681 ).

Implementation of music in colorectal perioperative standard care-barriers and facilitators among patients and healthcare professionals

AIM

Perioperative anxiety and pain are still prevalent among patients undergoing surgery. Inflammatory bowel disease and colorectal cancer patients are known to have higher anxiety rates than the general population. Perioperatively applied music intervention has been proven to be effective in reducing perioperative anxiety and pain, resulting in a decrease of intra-operative sedative use, postoperative opioid requirement and neurohormonal stress response. IMPROVE evaluates the adherence to music intervention in colorectal perioperative standard care during systematic implementation.

METHOD

The Consolidated Framework for Implementation Research (CFIR) was used for implementation in three steps. This study addresses the first step in which barriers and facilitators for implementing perioperative music were identified by surveying patients who underwent colorectal surgery and healthcare professionals involved in perioperative care. Also, perioperative anxiety scores were assessed and data on perioperative pain was collected from the patients' medical records.

RESULTS

Fifty patients and 69 professionals (response rate 68.3%) were surveyed. For patients, all domains of the CFIR were facilitating implementation. The median reported preoperative and postoperative anxiety scores were 4.5 (1.0-7.0) and 3.0 (1.0-5.75) respectively. The median postoperative pain score on the first postoperative day was 2.8 (2.0-3.7). Also, for professionals most domains were facilitating, except for some factors related to work climate and culture among nurses.

CONCLUSIONS

In this study it was identified that facilitating factors for implementing music in standard perioperative care were more prominent in both patients and healthcare professionals and therefore successful implementation is probable. Also, this study provides a guideline for assessing facilitators and barriers in other settings.

A multi-center, pragmatic, effectiveness-implementation (hybrid I) cluster randomized controlled trial to evaluate a child-oriented goal-setting approach in paediatric rehabilitation (the ENGAGE approach): a study protocol

BACKGROUND

Child-oriented goal-setting in pediatric rehabilitation may improve child motivation, engagement in therapy, child outcomes related to therapy, and service delivery efficiency. The primary objective of this trial is to determine the effectiveness of a principles-driven, child-focused approach to goal-setting, Enhancing Child Engagement in Goal-Setting (ENGAGE), on pediatric rehabilitation outcomes compared to usual practice. The three secondary objectives are to 1) compare costs and secondary outcomes of the ENGAGE approach to usual practice, 2) determine the influence of child, parent and therapist characteristics on child engagement in therapy and rehabilitation outcomes, and 3) identify barriers and facilitators to the implementation of ENGAGE.

METHODS

This research protocol describes a pragmatic, multi-site, cluster, effectiveness-implementation (hybrid type 1 design) randomized controlled trial. Therapists (n = 12 clusters of two therapists) at participating sites (n = 6) will be randomized to 1) the ENGAGE intervention group, or 2) usual care (control) using a computer-generated, permuted-block randomization sequence with site as a stratification variable designed by a statistician (RR). Each therapist will recruit four children 5-12 years old with neurodevelopmental conditions (n = 96), who will receive ENGAGE or usual care, according to therapist group allocation. ENGAGE therapists will be trained to use a 'toolbox' of evidence-driven, theory-informed principles to optimize child and parent motivation, engagement in the goal-setting process, and performance feedback strategies. Outcomes include goal performance (primary outcome), engagement in therapy, functional abilities, participation, and parent and child quality of life. Qualitative interviews with children, parents, ENGAGE therapists, and managers will explore challenges to implementation and potential mitigation strategies. Mixed effects multiple linear regression models will be developed for each outcome to assess group differences adjusted for clustering. A cost-effectiveness analysis will combine cost and a measure of effectiveness into an incremental cost-effectiveness ratio. Qualitative data on implementation will be analyzed inductively (thematic analysis) and deductively using established implementation science frameworks.

DISCUSSION

This study will evaluate the effects of collaborative goal-setting in pediatric rehabilitation and inform effective implementation of child-focused goal-setting practices.

TRIAL REGISTRATION

NCT05017363 (registered August 23, 2021 on ClinicalTrials.gov).

Hospital Employee Performance Evaluation Based on Knowledge Map

With the deepening of theoretical research and social practice, hospital employee performance management has developed into a mature knowledge system. Therefore, systematic review of the research results in this field is conducive to fully understand its research history, grasp the research hotspots and frontier issues, which is of great significance to theoretical innovation in the field of hospital employee performance evaluation.iteSpace 5.3.R4 was used as the visualization tool draw a knowledge map to systematically sort out the distribution of relevant literature of hospital employee performance evaluation, including time distribution, journal distribution, author distribution, etc., and conduct a systematic research on the research hotspots and research frontiers in the field of hospital employee performance evaluation, which provides a beneficial reference for the theoretical research and practical innovation of domestic hospital employee performance evaluation.

Comparing two federal financing strategies on penetration and sustainment of the adolescent community reinforcement approach for substance use disorders: protocol for a mixed-method study

BACKGROUND

Sustained, widespread availability of evidence-based practices (EBPs) is essential to address the public health and societal impacts of adolescent substance use disorders (SUD). There remains a particularly significant need to identify effective financing strategies, which secure and direct financial resources to support the costs associated with EBP implementation and sustainment. This protocol describes a new project comparing two types of U.S. federal grant mechanisms (i.e., a type of financing strategy), which supported the implementation of the Adolescent Community Reinforcement Approach (A-CRA) EBP for SUD, through either organization-focused or state-focused granting of funds. The Exploration-Preparation-Implementation-Sustainment (EPIS) framework will guide our study aims, hypotheses, and selection of measures.

METHOD

We will employ a longitudinal, mixed-method (i.e., web surveys, semi-structured interviews, document review, focus groups, administrative data), quasi-experimental design to compare the grant types' outcomes and examine theoretically informed mediators and moderators. Aim 1 will examine the proportion of eligible clinicians certified in A-CRA with adequate fidelity levels (i.e., penetration outcomes) at the end of grant funding. Aim 2 will examine the sustainment of A-CRA up to 5 years post-funding, using a 10-element composite measure of treatment delivery and supervision activities. We will integrate the new data collected from state-focused grant recipients (~85 organizations in 19 states) with previously collected data from organization-focused grant recipients (Hunter et al., Implement Sci 9:104, 2014) (82 organizations in 26 states) for analysis. We will also use sensitivity analyses to characterize the effects of observed and unobserved secular trends in our quasi-experimental design. Finally, aim 3 will use comparative case study methods (integrating diverse quantitative and qualitative measures) to identify and disseminate policy implications about the roles of state- and organization-focused federal grants in efforts to promote adolescent SUD EBP implementation and sustainment.

DISCUSSION

The proposed research will have direct, practical implications for behavioral health administrators, policymakers, implementation experts, and the public. It will offer new knowledge that can directly inform financing strategies to support large-scale, sustained EBP delivery in behavioral health-while advancing implementation science through the use of novel methods to study financing strategies and sustainment.

Behavioural optimisation to address trial conduct challenges: case study in the UK-REBOA trial

BACKGROUND

Clinical trials comprise multiple processes at various stages of the trial lifecycle. These processes often involve complex behaviours such as recruiting vulnerable patient populations and clinicians having to deliver complex trial interventions successfully. Few studies have utilised a behavioural framework to assess challenges and develop strategies for effective trial recruitment and delivery of trial interventions. This study reports the application of an innovative methodological approach to understand core trial processes, namely recruitment and intervention delivery, using a behavioural science approach to develop strategies designed to mitigate trial process problems.

METHODS

The UK-REBOA trial aims to evaluate the clinical and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta (a novel intervention) in injured patients with exsanguinating haemorrhage. A behavioural investigation ('diagnosis') was conducted using theory-informed (Theoretical Domains Framework, TDF) semi-structured interviews with site staff from the UK-REBOA trial to examine trial processes which could be improved in relation to trial recruitment and delivery of the intervention. Interviews were analysed using the TDF to identify influences on behaviour, which were then mapped to techniques for behaviour change and developed into potential solutions.

RESULTS

The behavioural diagnosis of the challenges experienced during trial processes highlighted factors relevant to a range of TDF domains: Skills, Environmental context and resources, Beliefs about capabilities, Beliefs about consequences, Social influences, and Memory, attention, and decision-making processes. Within the solution development phase, we identified 24 suitable behaviour change techniques that were developed into proposed solutions to target reported process problems with the aim of changing behaviour to improve recruitment and/or intervention delivery. Proposed solutions included targeted changes to trial training content, suggestions to restructure the environment (e.g. reinforced the purpose of the trial with information about the social and environmental consequences) and other strategies to reduce barriers to recruitment and intervention delivery.

CONCLUSIONS

This study demonstrates the feasibility of applying a behavioural approach to investigate ('diagnose') behavioural trial process problems and subsequently develop and implement targeted solutions ('treatment') in an active trauma trial. Understanding the factors that affected behaviour, attitudes and beliefs in this trauma trial allowed us to implement theoretically informed, evidence-based solutions designed to enhance trial practices.

TRIAL REGISTRATION

ISRCTN 16,184,981.

Implementation of a complex intervention to reduce hospitalizations from nursing homes: a mixed-method evaluation of implementation processes and outcomes

Background | objective

To evaluate the implementation of three intervention elements to reduce hospitalizations in nursing home residents.

Design

Convergent mixed-method design within a hybrid type-2 effectiveness-implementation study.

Setting

Eleven nursing homes in the German-speaking region of Switzerland.

Participants

Quantitative data were collected from 573 care workers; qualitative data were collected from 108 care workers and the leadership from 11 nursing homes.

Intervention

Three intervention elements targeting care workers were implemented to reduce unplanned hospitalizations: (1) the STOP&WATCH instrument for early recognition of changes in resident condition; (2) the ISBAR instrument for structured communication; and (3) specially-trained INTERCARE nurses providing on-site geriatric support. Multifaceted implementation strategies focusing both on the overall nursing home organization and on the care workers were used.

Methods

The quantitative part comprised surveys of care workers six- and twelve-months post-intervention. The intervention’s acceptability, feasibility and uptake were assessed using validated and self-developed scales.

Qualitative data were collected in 22 focus groups with care workers, then analyzed using thematic analysis methodology. Data on implementation processes were collected during implementation meetings with nursing home leadership and were analyzed via content analysis. Findings were integrated using a complementary approach.

Results

The ISBAR instrument and the INTERCARE nurse role were considered acceptable, feasible, and taken up by > 70% of care workers. The STOP&WATCH instrument showed the lowest acceptance (mean: 68%), ranging from 24 to 100% across eleven nursing homes. A combination of factors, including the amount of information received, the amount of support provided in daily practice, the users’ perceived ease of using the intervention and its adaptations, and the intervention’s usefulness, appeared to influence the implementation’s success. Two exemplary nursing homes illustrated context-specific implementation processes that serve as either barriers or facilitators to implementation.

Conclusions

Our findings suggest that, alongside the provision of information shortly before intervention start, constant daily support is crucial for implementation success. Ideally, this support is provided by designated and trained individuals who oversee implementation at the organizational and unit levels. Leaders who seek to implement interventions in nursing homes should consider their complexity and their consequences for workflow to optimize implementation processes accordingly.

Trial registration

This study was registered at clinicaltrials.gov (NCT03590470) on the 18/06/2018.

Perceived Factors of Influence on the Implementation of a Multidimensional Project to Improve Patients' Movement Behavior During Hospitalization: A Qualitative Study

OBJECTIVE

The aim of this study was to explore perceived factors of influence on the implementation of Hospital in Motion, a multidimensional and multidisciplinary implementation project to improve inpatients' movement behavior.

METHODS

This qualitative study was conducted on 4 wards. Per ward, a tailored action plan was implemented consisting of multiple tools and interventions to stimulate the integration of inpatient physical activity in usual care processes. After implementation, semi-structured interviews were performed with health care professionals and patients to explore perceived factors of influence on the implementation of the Hospital in Motion project. A content analysis was performed using the framework of the Medical Research Council for complex interventions as guidance for the identification of categories and themes.

RESULTS

In total, 16 interviews were conducted with health care professionals and 12 with patients. The results were categorized into the 3 key components of the Medical Research Council framework: implementation, mechanisms of impact, and context. An important factor of influence within the theme "implementation" was the iterative and multidisciplinary approach. Within the theme "mechanisms of impact," continuous attention and the interaction of multiple interventions, tailored to the target group and targeting multiple dimensions (individual, inter-professional, community and society), were perceived as important. Within the theme "context," the intrinsic motivation and inter-professional, community and societal culture towards physical activity was perceived to be of influence.

CONCLUSION

Impact can be achieved and maintained by creating continuous attention to inpatient physical activity and by the interaction between different interventions and dimensions during implementation. To maintain enough focus, the amount of activities at one time should be limited.

IMPACT

To improve inpatients' movement behavior, implementation project teams should be multidisciplinary and should implement a small set of tailored interventions that target multiple dimensions. Intermediate evaluation of the implementation process, strategies, and interventions is recommended.

Coordination of sustainable financing for evidence-based youth mental health treatments: protocol for development and evaluation of the fiscal mapping process

BACKGROUND

Sustained delivery of evidence-based treatments (EBTs) is essential to addressing the public health and economic impacts of youth mental health problems, but is complicated by the limited and fragmented funding available to youth mental health service agencies (hereafter, "service agencies"). Strategic planning tools are needed that can guide these service agencies in their coordination of sustainable funding for EBTs. This protocol describes a mixed-methods research project designed to (1) develop and (2) evaluate our novel fiscal mapping process that guides strategic planning efforts to finance the sustainment of EBTs in youth mental health services.

METHOD

Participants will be 48 expert stakeholder participants, including representatives from ten service agencies and their partners from funding agencies (various public and private sources) and intermediary organizations (which provide guidance and support on the delivery of specific EBTs). Aim 1 is to develop the fiscal mapping process: a multi-step, structured tool that guides service agencies in selecting the optimal combination of strategies for financing their EBT sustainment efforts. We will adapt the fiscal mapping process from an established intervention mapping process and will incorporate an existing compilation of 23 financing strategies. We will then engage participants in a modified Delphi exercise to achieve consensus on the fiscal mapping process steps and gather information that can inform the selection of strategies. Aim 2 is to evaluate preliminary impacts of the fiscal mapping process on service agencies' EBT sustainment capacities (i.e., structures and processes that support sustainment) and outcomes (e.g., intentions to sustain). The ten agencies will pilot test the fiscal mapping process. We will evaluate how the fiscal mapping process impacts EBT sustainment capacities and outcomes using a comparative case study approach, incorporating data from focus groups and document review. After pilot testing, the stakeholder participants will conceptualize the process and outcomes of fiscal mapping in a participatory modeling exercise to help inform future use and evaluation of the tool.

DISCUSSION

This project will generate the fiscal mapping process, which will facilitate the coordination of an array of financing strategies to sustain EBTs in community youth mental health services. This tool will promote the sustainment of youth-focused EBTs.

What to consider when implementing a tool for timely recognition of palliative care needs in heart failure: a context-based qualitative study

BACKGROUND

Needs assessment tools can facilitate healthcare professionals in timely recognition of palliative care needs. Despite the increased attention for implementation of such tools, most studies provide little or no attention to the context of implementation. The aim of this study was to explore factors that contribute positively and negatively to timely screening of palliative care needs in advanced chronic heart failure.

METHODS

Qualitative study using individual interviews and focus groups with healthcare professionals. The data were analysed using a deductive approach. The Consolidated Framework for Implementation Research was used to conceptualise the contextual factors.

RESULTS

Twenty nine healthcare professionals with different backgrounds and working in heart failure care in the Southern and Eastern parts of the Netherlands participated. Several factors were perceived to play a role, such as perception and knowledge about palliative care, awareness of palliative care needs in advanced chronic heart failure, perceived difficulty when and how to start palliative care, limited acceptance to treatment boundaries in cardiology, limited communication and collaboration between healthcare professionals, and need for education and increased attention for palliative care in advanced chronic heart failure guidelines.

CONCLUSIONS

This study clarified critical factors targeting patients, healthcare professionals, organisations to implement a needs assessment tool for timely recognition of palliative care needs in the context of advanced chronic heart failure. A multifaceted implementation strategy is needed which has attention for education, patient empowerment, interdisciplinary collaboration, identification of local champions, chronic heart failure specific guidelines and culture.

Sustaining acute speech-language therapists' implementation of recommended aphasia practices: A mixed methods follow-up evaluation of a cluster RCT

BACKGROUND

While implementation studies in aphasia management have shown promising improvements to clinical practice, it is currently unknown if aphasia implementation outcomes are sustained and what factors may influence clinical sustainability.

AIMS

To evaluate the sustainment (i.e., sustained improvement of aphasia management practices and domains influencing clinicians' practice) and sustainability (i.e., factors influencing sustainability) outcomes of the Acute Aphasia IMplementation Study (AAIMS).

METHODS & PROCEDURES

A convergent interactive mixed-methods sustainability evaluation was conducted on two previously delivered implementation interventions (AAIMS). The AAIMS interventions were targeted at improving either written aphasia-friendly information provision (Intervention A) or collaborative goal-setting (Intervention B). Outcomes were collected 2 and 3 years post-implementation, addressing the research questions of sustainment (e.g., medical record audits and behavioural constructs questionnaires) and sustainability (e.g., post-study focus groups and organizational readiness surveys). Quantitative sustainability data were compared with post-implementation data, allowing for sustainment to be determined. Clinicians' perspectives on sustainability outcomes and challenges were analysed using framework analysis and integrated with the quantitative findings.

OUTCOMES & RESULTS

A total of 35 speech-language therapists (SLTs) from four hospitals participated. The medical records of 79 patients were audited in the sustainability period compared with the 107 medical records audited during AAIMS. Overall, there was variable sustainment of the target behaviours; implementation for Intervention A was not sustained at either sustainability time point (2018 = 47.8% decrease; 2019 = 22.78% decrease), but implementation for Intervention B was sustained at both time points (2018 = 7.78% increase; 2019 = 18.1% increase). There was a pattern of sustained change in the behaviour change domains targeted by the implementation interventions, where scores of the targeted domains increased over time (0.13, 95% confidence interval (CI) = -0.05 to 0.30) and scores of the non-targeted domains declined (-0.03, 95% CI = -0.11 to 0.04). Factors influencing sustainability were mainly related to 'processes', 'the inner context' and 'SLT characteristics', and these interacted dynamically to account for variation between teams.

CONCLUSIONS & IMPLICATIONS

Implementation outcomes (i.e., practice changes) were not sustained to the same level for three of the four participating SLT teams, with variable or partial sustainment most common. While the factors influencing sustainability differed depending on the context and individuals involved, the most important factor influencing outcomes seemed to be the level to which behaviour-change processes and strategies were embedded within the SLT department. Future implementation studies should incorporate sustainability measures from the onset and include follow-ups and monitoring systems to help support sustained change in the long term.

WHAT THIS PAPER ADDS

What is already known on the subject In post-stroke aphasia management, there are few examples of long-term sustainability of implementation outcomes. It is therefore unknown what factors are potentially important to sustain implementation of best-practice recommendations in aphasia services. What this paper adds to existing knowledge There is potential for implementation outcomes to be sustained long term, but sustainment is impacted by a range of factors. Ongoing facilitation or follow-up after initial implementation may to useful to promote sustainment, but is not essential if processes are sufficiently embedded. Gradual implementation into practice may lead to better sustainment than rapid change that is quickly forgotten. What are the potential or actual clinical implications of this work? Future implementation efforts should incorporate sustainability measures from the onset. Applying a sustainability framework was useful to guide evaluations and explore factors influencing the sustainment outcomes and is recommended for those interested in sustainability. Results from our evaluation can be used to guide refinement and support future development of sustainable implementation interventions.

Sustaining a nursing best practice guideline in an acute care setting over 10 years: A mixed methods case study

Background

To improve patient outcomes many healthcare organizations have undertaken a number of steps to enhance the quality of care, including the use of evidence-based practices (EBPs) such as clinical practice guidelines. However, there is little empirical understanding of the longer-term use of guideline-based practices and how to ensure their ongoing use. The aim of this study was to identify the determinants and knowledge translation interventions (KTIs) influencing ongoing use of selected recommendations of an institutional pain policy and protocol over time from an organizational perspective and 10 years post implementation on two units within an acute care setting.

Methods

We conducted a mixed methods case study guided by the Dynamic Sustainability Framework of an EBP 10 years post implementation. We examined protocol sustainability at the nursing department and unit levels of a multi-site tertiary center in Canada. Data sources included document review (n = 29), chart audits (n = 200), and semi-structured interviews with nurses at the department (n = 3) and unit (n = 16) level.

Results

We identified 32 sustainability determinants and 29 KTIs influencing ongoing use of an EBP in acute care. Three determinants and eight KTIs had a continuous influence in all three time periods: implementation phase (0-2 yrs), sustained phase (>2-10 yrs.), and at the 10-year mark. Implementation of KTIs evolved with the level of application (e.g., department vs. unit) to fit the EBP within the context highlighting the need to focus on determinants influencing ongoing use. Sustainability was associated with continual efforts of monitoring and providing timely feedback regarding adherence to recommendations. KTIs used to embed recommendations into routine practices/processes positively influenced high adherence rates. Use of a participatory approach for implementation and sustainment and linking KTIs designed to incrementally address low adherence rates facilitated sustainment.

Conclusion

This research provides insight into the relationship between implementation and sustainability determinants and related KTIs during implementation and sustained use phases. Unique determinants identified by department and unit nurses reflect their different perspectives toward the innovation based on their respective roles and responsibilities. KTIs fostered changed behaviors and facilitated EBP sustainment in acute care. Findings confirm the concept of sustainability is a dynamic "ongoing process."

Extrinsic and intrinsic factors acting as barriers or facilitators in nurses' implementation of clinical practice guidelines: a mixed-method systematic review

BACKGROUND AND AIM OF THE WORK

Greater evaluations are needed to identify barriers or facilitators in nurses' guidelines adherence. The current review aims to explore extrinsic and intrinsic factors impacting nurses' compliance.

METHODS

Mixed-method systematic review with a convergent approach, following the PRISMA checklist and the JBI Mixed Methods Review Methodological Guidance was conducted. MEDLINE, Embase, CINAHL were systematically searched, to find studies published between 2010 and 2021, including qualitative, quantitative or mixed-methods articles.

RESULTS

Sixty studies were included, and the major findings were analysed by aggregating them in two main themes: intrinsic and extrinsic factors. The intrinsic factors were: a) knowledge and skills; b) attitudes of health personnel; c) sense of belonging towards guidelines. The extrinsic factors were: a) organizational and environmental factors; b) workload; c) guidelines structure; d) patients and caregivers' attitude.

CONCLUSIONS

The included studies report lack of resources, among environmental factors, as the main barrier perceived. Nurses, who are at the forefront in addressing the direct application of knowledge and skills to ensure patient safety, have a higher perception of this kind of barriers than other healthcare personnel. Potential facilitators emerged in the review are positive feedback and reinforcements at the workplace, either from the members of the team or from the leaders. Moreover, the level of active participation of the patient and caregiver could have a positive impact on nurses' guidelines adherence. Guidelines implementation remains a complex process, resulting in a strong recommendation to support health policymakers and nursing leaders in implementing continuing education programs.

Effect of after action review on safety culture and second victim experience and its implementation in an Irish hospital: A mixed methods study protocol

Background

After Action Review is a form of facilitated team learning and review of events. The methodology originated in the United States Army and forms part of the Incident Management Framework in the Irish Health Services. After Action Review has been hypothesized to improve safety culture and the effect of patient safety events on staff (second victim experience) in health care settings. Yet little direct evidence exists to support this and its implementation has not been studied.

Aim

To investigate the effect of After Action Review on safety culture and second victim experience and to examine After Action Review implementation in a hospital setting.

Methods

A mixed methods study will be conducted at an Irish hospital. To assess the effect on safety culture and second victim experience, hospital staff will complete surveys before and twelve months after the introduction of After Action Review to the hospital (Hospital Survey on Safety Culture 2.0 and Second Victim Experience and Support Tool). Approximately one in twelve staff will be trained as After Action Review Facilitators using a simulation based training programme. Six months after the After Action Review training, focus groups will be conducted with a stratified random sample of the trained facilitators. These will explore enablers and barriers to implementation using the Theoretical Domains Framework. At twelve months, information will be collected from the trained facilitators and the hospital to establish the quality and resource implications of implementing After Action Review.

Discussion

The results of the study will directly inform local hospital decision-making and national and international approaches to incorporating After Action Review in hospitals and other healthcare settings.