Advancing theory on the multilevel role of leadership in the implementation of evidence-based health care practices

What Should Healthcare Systems Consider When Modernizing Call Centers? Early Considerations From the Veterans Health Administration

GOAL

Growing numbers of hospitals and payers are using call centers to answer patients' clinical and administrative questions, schedule appointments, address billing issues, and offer supplementary care during public health emergencies and national disasters. In 2020, the Veterans Health Administration (VA) implemented VA Health Connect, an enterprise-wide initiative to modernize call centers. VA Health Connect is designed to improve the care experience with the convenience, flexibility, and simplicity of a single toll-free number connected to a range of 24/7 virtual services. The services are organized into four areas: administrative guidance for scheduling and general inquiries; pharmacy support for medication matters; clinical triage for evaluation of symptoms and recommended care; and virtual visits with providers for urgent and episodic care. Through a qualitative evaluation of VA Health Connect, we sought to identify the factors that affected the development of this program and to compile considerations to support the implementation of other enterprise-wide initiatives.

METHODS

The evaluation team interviewed 29 clinical and administrative leads from across the VA. These leads were responsible for the modernization of their local service networks. PhD-level qualitative methodologists conducted the interviews, asking participants to reflect on barriers and facilitators to modernization and implementation. The team employed a rapid qualitative analytic approach commonly used in healthcare research to distill robust results.

PRINCIPAL FINDINGS

A review of the early implementation of VA Health Connect found: (1) deadlines proved challenging but provided momentum for the initiative; (2) a balance between standardized processes and local adaptations facilitated implementation; (3) attention to staffing, hiring, and training of call center staff before implementation expedited workflows; (4) establishing national and local leadership commitment to the innovation from the onset increased team cohesion and efficacy; and (5) anticipating information technology infrastructure needs prevented delays to modernization and implementation.

PRACTICAL APPLICATIONS

Our findings suggest that healthcare systems would benefit from anticipating likely obstacles (e.g., delays in software implementations and negotiations with unions), thus providing ample time to secure leadership buy-in and identify local champions, communicating early and often, and supporting flexible implementation to meet local needs. VA leadership can use this evaluation to refine implementation, and it could also have important implications for regulators, federal health exchanges, insurers, and other healthcare systems when determining resource levels for call centers.

Role of Magnet®-recognized hospital nurse managers in implementing evidence-based practice: A mixed-method study

BACKGROUND

Healthcare systems recognize evidence-based practice (EBP) as the prestigious standard for providing safe and high-quality patient care, nursing excellence, and Magnet Recognition. Despite the well-documented benefits, implementation of EBP is inconsistent and remains elusive in the US and throughout the world and many patients still fail to receive evidence-based care. The literature revealed a huge gap between nursing science and practice but provided evidence that nurse managers (NMs) had a pivotal leadership role in implementing EBP.

AIM

To gain a deeper understanding of Magnet-recognized hospital nurse managers' (MRHNMs) leadership roles, the influencing factors, and their experience in implementing EBP to enhance EBP initiatives and sustain Magnet recognition.

METHOD

This mixed-method study guided by Goodall's (Australasian Psychiatry, 2016. 24, 231) theory of expert leadership used a sequential explanatory method with a quantitative-driven design based on a national correlational survey augmented by a qualitative descriptive component using semi-structured interviews.

RESULTS

The findings of the study demonstrated that MRHNMs had a 54.6% effective leadership role in implementing EBP and produced numerous themes indicating that MRHNMs did implement EBP with struggle. MRHNMs in this study viewed EBP as a healthcare priority and leadership of NMs is necessary to promote EBP. However, lack of knowledge, difficulties with the EBP process, time constraints, and staffing issues negatively impacted EBP. Postgraduate degree, formal EBP education, critical care units as workplace, collaboration with doctorally prepared nurses, and Magnet culture enhanced EBP among MRHNMs.

LINKING EVIDENCE TO ACTION

EBP is essential for Magnet recognition and is a hallmark of nursing excellence, however, is a complex and challenging process. The leadership of NMs is necessary to shape evidence-based care, and NMs require EBP preparation during leadership training, necessary resources, and time to complete the EBP process. EBP cannot become a reality without leaders being engaged, supportive, and persistent.

Adoption of Electronic Health Record Among Substance Use Disorder Treatment Programs: Nationwide Cross-Sectional Survey Study

BACKGROUND

Electronic health record (EHR) systems have been shown to be associated with improvements in care processes, quality of care, and patient outcomes. EHR also has a crucial role in the delivery of substance use disorder (SUD) treatment and is considered important for addressing SUD crises, including the opioid epidemic. However, little is known about the adoption of EHR in SUD treatment programs or the organizational-level factors associated with the adoption of EHR in SUD treatment.

OBJECTIVE

We examined the adoption of EHR in SUD programs, with a focus on changes in adoption from 2014 to 2017, and identified organizational-level factors associated with EHR adoption.

METHODS

We used data from the 2014 and 2017 National Drug Abuse Treatment System Surveys. Our analysis included 1027 SUD programs (531 in 2014 and 496 in 2017). We used chi-square and Mann-Whitney U tests for categorical and continuous variables, respectively, to assess changes in EHR adoption, technology use, program, and client characteristics. We also investigated differences in characteristics and barriers to adoption by EHR adoption status (adopted EHR vs had not adopted or were planning to adopt EHR). We then conducted multivariate logistic regressions to examine internal and external factors associated with EHR adoption.

RESULTS

The adoption of EHR increased significantly from 57.6% (306/531) in 2014 to 69.2% (343/496) in 2017 (P<.001), showing that nearly one-third (153/496, 30.8%) of SUD programs had not yet adopted an EHR system by 2017. We identified a significant increase in technology use and ownership by a parent company (P=.01 and P<.001) and a decrease in the percentage of uninsured patients in 2017 (P<.001), compared to 2014. Our analysis further showed significant differences by adoption status for three major barriers to adoption: (1) start-up costs, (2) ongoing financial costs, and (3) privacy or security concerns (P<.001). Programs that used computerized scheduling (adjusted odds ratio [AOR] 3.02, 95% CI 2.23-4.09) and billing systems (AOR 2.29, 95% CI 1.62-3.25) were more likely to adopt EHR. Similarly, ownership type, such as private nonprofit (AOR 1.86, 95% CI 1.31-2.65) and public (AOR 2.14, 95% CI 1.27-3.67), or interest in participating in a patient-centered medical home (AOR 1.93, 95% CI 1.29-2.92), were associated with an increased likelihood to adopt EHR. Overall, SUD programs were more likely to adopt an EHR system in 2017 compared to 2014 (AOR 1.44, 95% CI 1.07-1.94).

CONCLUSIONS

Our findings highlighted that SUD programs may be on track to achieve widespread EHR adoption. However, there is a need for focused strategies, resources, and policies explicitly designed to systematically address barriers and tackle obstacles to expanding the adoption of EHR systems. These efforts must be holistic and address factors at multiple organizational levels.

Effects of a multi-component alcohol prevention program in the workplace on hazardous alcohol use among employees

BACKGROUND

The workplace can be affected negatively by hazardous alcohol use, and intervening at an early stage remains a challenge. Recently, a multi-component alcohol prevention program, Alcohol Policy and Managers' skills Training (hereafter, 'APMaT'), was delivered at the organizational level. In a previous outcome evaluation, APMaT appeared to be effective at the managerial level. The current study takes a step further by aiming to evaluate the effectiveness of APMaT in decreasing the alcohol risk level among employees.

METHODS

Data from 853 employees (control: n = 586; intervention: n = 267) were gathered through a cluster-randomized study. To analyze changes in the odds of hazardous alcohol use among employees, multilevel logistic regression was applied using group (control vs. intervention), time (baseline vs. 12-month follow-up), and the multiplicative interaction term (group × time) as the main predictors. The intervention effect was further adjusted for sociodemographic characteristics and policy awareness.

RESULTS

No statistically significant difference was observed in the odds of hazardous alcohol use, although employees in the intervention group showed a larger decrease compared to the control group. This remained even after adjusting for several factors, including the sociodemographic factors and policy awareness.

CONCLUSIONS

The findings are insufficient to determine the effectiveness of APMaT at the employee level at the current stage of the evaluation. Future studies should strive to identify issues with implementation processes in workplace-based alcohol interventions.

TRIAL REGISTRATION

The trial was retrospectively registered on 11/10/2019; ISCRTN ID: ISRCTN17250048.

Individual-level associations between implementation leadership, climate, and anticipated outcomes: a time-lagged mediation analysis

BACKGROUND

Leaders can improve implementation outcomes by developing an organizational climate conducive to the implementation of evidence-based practices (EBP). This study tested the lagged associations between individual-level perceptions of implementation leadership, implementation climate, and three anticipated implementation outcomes, that is EBP acceptability, appropriateness, and feasibility.

METHODS

Screening tools and treatment methods for posttraumatic stress disorder were implemented in 43 Norwegian mental health services. A sample of 494 child and adult mental health care professionals (M = 43 years, 78% female) completed surveys addressing perceptions of first-level leaders' (n = 47) implementation leadership and their clinics' implementation climate. Single-level structural equation models estimating both direct, indirect, and total effects were used to investigate whether perceived implementation climate mediated the association between perceived implementation leadership and perceived acceptability, appropriateness, and feasibility of screening tools and treatment methods.

RESULTS

Regarding the treatment methods, implementation leadership was associated with therapists' perceptions of acceptability, appropriateness, and feasibility. Implementation climate also mediated between implementation leadership and the outcomes. Regarding the screening tools, implementation leadership was not associated with the outcomes. However, implementation climate mediated between implementation leadership and therapists' perceptions of acceptability and feasibility, but not appropriateness. Analyses with the implementation climate subscales showed stronger associations for therapists' perceptions of the treatment methods than of screening tools.

CONCLUSIONS

Leaders may promote positive implementation outcomes, both directly and through implementation climate. With regard to the effect sizes and explained variance, results indicated that both implementation leadership and implementation climate were more strongly associated with the therapists' perceptions of the treatment methods, implemented by one group of therapists, than the screening tools, implemented by all therapists. This may imply that implementation leadership and climate may have stronger effects for smaller implementation teams within a larger system than for system-wide implementations or when the clinical interventions being implemented are more complex rather than simple ones.

TRIAL REGISTRATION

ClinicalTrials NCT03719651, 25 October 2018.

Individual and organizational factors as predictors of early evidence-based practice adoption in Michigan high schools: Baseline data from an implementation trial

Background

Adolescents increasingly access mental health services in schools. School mental health professionals (SPs; school counselors, social workers, etc.) can offer evidence-based mental health practices (EBPs) in schools, which may address access gaps and improve clinical outcomes. Although some studies have assessed factors associated with EBP adoption in schools, additional research focusing on SP- and school-level factors is warranted to support EBP implementation as SPs’ mental health delivery grows.

Methods

Baseline data were collected from SPs at Michigan high schools participating in a statewide trial to implement SP-delivered cognitive behavioral therapy (CBT) to students. Models examined factors associated with attitudes about EBPs, implementation climate, and implementation leadership, and their associations with CBT knowledge, training attendance, and pre-training CBT delivery.

Results

One hundred ninety-eight SPs at 107 schools (87%) completed a baseline survey. The mean Evidence-Based Practice Attitude Scale (EBPAS) total score was 2.9, and school-aggregated mean scores of the Implementation Climate Scale (ICS) and Implementation Leadership Scale (ILS) were 1.83 and 1.77, respectively, all on a scale ranging from 0 ( low) to 4 ( high). ICS and ILS scores were lower than typically reported in clinical settings, while EBPAS scores were higher. School characteristics were not significantly associated with EBPAS, ICS, or ILS scores, but scores did differ by SP role. Higher EBPAS scores were associated with more CBT knowledge (average marginal effect for 1 SD change [AME] = 0.15 points) and a higher probability of training completion (AME = 8 percentage points). Higher ICS scores were associated with a higher probability of pre-training CBT delivery (AME = 6 percentage points), and higher ILS scores were associated with higher probability of training completion (AME = 10 percentage points).

Conclusions

Our findings suggest that SPs’ attitudes toward EBPs and organizational support were positively associated with early signs of implementation success. As schools increasingly fill the adolescent mental healthcare access gap, efforts to strengthen both provider attitudes toward EBP and strategic organizational factors supporting EBP delivery will be key to encouraging EBP uptake in schools.

Plain Language Summary

Schools are an important setting in which adolescents receive mental healthcare. We need to better understand how to implement evidence-based practices (EBPs) in this setting to improve student mental health. This study examined the attitudes and perceptions of school professionals (SPs) as key contributors to the implementation of a particular EBP, the delivery of cognitive behavioral therapy (CBT) in schools. The study found that implementation climate and leadership scores in participating schools were lower than scores typically reported in clinical settings, while scores for SP attitudes about EBP adoption were higher than typical scores in clinical settings. Results further suggest that SPs with more positive attitudes toward EBPs are more knowledgeable of CBT and more likely to complete a 1-day CBT training. We also found that higher implementation climate scores were associated with SPs reporting pre-training CBT delivery (although this association was not statistically significant), and more implementation leadership was associated with SPs completing the CBT training. These findings suggest that SP attitudes toward EBPs and organizational support in schools are positively associated with early signs of implementation success. Early, low-intensity efforts to (1) improve SP attitudes about mental health EBPs, and (2) increase schools’ support for implementation may scaffold more intensive implementation efforts in schools down the road.

Benefits, Barriers and Determinants of Clinical Pathway Use in Germany, Austria and Switzerland. A pilot study

BACKGROUND

Performance-oriented financing of healthcare aims at demand-based and efficient resource allocation. Often, clinical pathways (CPs) are introduced in this context.

PURPOSE

For CP success (a) the degree of utilization of and divergence, (b) cost effects and (c) health professionals' acceptance rate of and satisfaction are relevant. There are gaps in research regarding these issues in general, and more specifically in the German speaking part of Europe.

METHODOLOGY/APPROACH

Employing a two-stage mixed-methods pilot study, we studied (a) and (b) quantitatively in Germany, Austria, and Switzerland, and (c) qualitatively in Germany and Austria.

RESULTS

Many hospitals already implemented CPs, but the utilization varies. They are expected to yield middle-range savings, but intangible benefits are more important. In general, employees are in favor of CPs, but several conditions need to be met, e.g. adaptability to local requirements.

CONCLUSION

Linking the results to the Consolidated Framework for Implementation Research showed many criteria are covered, which might lead to the positive evaluations, but also highlights the complexity of the intervention.

PRACTICE IMPLICATION

As enhanced acceptance rates are expected to lead to higher benefits and vice versa, management team should safeguard employee participation and perceived benefits in all phases of the CP cycle.

Practice change in community health centers: A qualitative study of leadership attributes

Introduction

This paper explores leadership attributes important for practice change in community health centers (CHCs) and assesses attributes' fit with the Full-Range Leadership Theory (FRLT).

Methods

We conducted four focus groups and 15 in-depth interviews with 48 CHC leaders from several U.S. states using a modified appreciative inquiry approach. Thematic analysis was used to review transcripts for leadership concepts and code with a priori FRLT-derived and inductive codes.

Results

CHC leaders most often noted attributes associated with transformational leadership as essential for practice change. Important attributes included emphasizing a collective sense of mission and a compelling, achievable vision; expressing enthusiasm about what needs to be done; and appealing to employees' analytical reasoning and challenging others to think creatively to problem solve. Few expressions of leadership fit with the transactional typology, though some did mention active vigilance to ensure standards are met, clarifying role and task requirements, and rewarding followers. Passive-avoidant attributes were rarely mentioned.

Conclusions

Our results enhance understanding of leadership attributes supportive of successful practice change in CHCs.

Community-based implementation strategy use and satisfaction: A mixed-methods approach to using the ERIC compilation for organizations serving children on the autism spectrum

Background

Despite efforts to use standardized taxonomy and research reporting, documenting implementation strategies utilized in community settings remains challenging. This case study demonstrates a practical approach to gather use of and satisfaction with implementation strategies utilized within community-based sites to understand community providers’ perspectives of implementing an early intensive behavioral intervention (EIBI) for children on the autism spectrum across different settings.

Methods

Using a sequential explanatory mixed-methods design, survey and interview data were collected from directors/supervisors and direct providers ( n = 26) across three sites (one university and two community-based replication sites). The Implementation Strategies and Satisfaction Survey (ISSS) was administered to identify staff-reported implementation strategy use and satisfaction. Informed by quantitative results, follow-up semi-structured interviews were conducted with a subsample ( n = 13) to further understand staff experiences with endorsed implementation strategies and elicit recommendations for future efforts.

Results

Survey results were used to demonstrate frequencies of implementation strategies endorsed by site and role. Overall, staff felt satisfied with implementation strategies used within their agencies. Content analysis of qualitative data revealed three salient themes related to implementation strategy use—context, communication, and successes and challenges—providing in-depth detail on how strategies were utilized, and strategy effectiveness based on community providers’ experiences. Recommendations were also elicited to improve strategy use within “broader” community settings.

Conclusions

The project demonstrated a practical approach to identifying and evaluating implementation strategies used within sites delivering autism services. Reporting implementation strategies using the ISSS can provide insight into community providers’ perspectives and satisfaction with agency implementation strategy use that can generate more relevant and responsive strategies to address barriers in community settings. Plain language abstract Examining community providers’ preferences and experiences with implementation strategies used to facilitate evidence-based practice uptake can broaden our understanding of what, how, and why implementation strategies work in community-based settings ( Chaudoir et al., 2013 ; Leeman et al., 2017 ; Proctor et al., 2013 ). Such efforts have great potential to tailor implementation strategies to address barriers/facilitators typically found in community-based settings. This case study demonstrates a practical approach using mixed methodology to: (a) gather self-reported use of and satisfaction with implementation strategies to understand community providers’ perspectives of implementation strategy success. Using a new survey, the Implementation Strategies and Satisfaction Survey (ISSS) conjoined with interviews, the study demonstrated a practical approach using standardized language to report strategies used in one university-based site and two community-based replication sites that deliver an early intensive behavioral intervention (EIBI) for children on the autism spectrum. This paper contributes to one of the five priorities to enhance public health impact—improve tracking and reporting of implementation strategies utilized when translating research into practice ( Dingfelder & Mandell, 2011 ; Powell et al., 2019 ; Stahmer et al., 2019 ). This approach emphasizes the importance of understanding context (e.g., community organizations providing services to children on the autism spectrum) to develop strategies that work better for EIBI implementation and scale-up. Understanding community provider's preferences and experiences with implementation strategies can support use of implementation strategies that better fit usual care contexts, with the ultimate goal of improving implementation practice in community-based settings.

The relationship between first-level leadership and inner-context and implementation outcomes in behavioral health: a scoping review

BACKGROUND

First-level leadership is uniquely positioned to support evidence-based practice (EBP) implementation for behavioral health due to first-level leaders' access to and relationship with service providers. First-level leaders are individuals who directly supervise and manage frontline employees who do not manage others. However, first-level leadership is underrepresented in existing reviews of the impact of leadership on EBP implementation. This review describes the relationship between first-level leadership and implementation determinants and outcomes.

METHODS

A scoping review was performed to synthesize the literature on the relationship between first-level leadership and inner-context and implementation outcomes. A literature search was conducted in PubMed, Eric, PsycINFO, CINAHL, Scopus, and Web of Science. To be eligible, studies had to examine first-level leadership, be conducted in settings providing behavioral health services, and examine the relationship between first-level leadership and an implementation or inner-context outcome. Data extraction and synthesis were performed to describe study characteristics, leader-outcome relationships, and overlap in leadership frameworks.

RESULTS

Twenty-one records met our inclusion criteria. Studies primarily relied on observational designs and were often cross-sectional. Studies more often examined general leadership rather than leadership strategically focused on EBP implementation (i.e., strategic implementation leadership). Our findings suggest that several forms of first-level leadership are inconsistently related to a broad set of implementation determinants, with infrequent examination of specific implementation outcomes. The broad set of implementation determinants studied, limited number of replications, and inconsistent findings have resulted in sparse evidence for any specific leadership-outcome relationship. The greatest accumulation of evidence exists for general leadership's positive relationship with providers' EBP attitudes, most notably in the form of transformational leadership. This was followed by evidence for strategic implementation leadership facilitating general implementation. Our synthesis revealed moderate conceptual overlap of strategic implementation leadership behaviors described in the theory of implementation leadership and theory of middle managers' role in implementation.

CONCLUSIONS

Our findings suggest that first-level leadership may play an important role in shaping implementation determinants and outcomes, but consistent empirical support is sparse and confidence dampened by methodological issues. To advance the field, we need studies that adopt stronger methodological rigor, address the conceptual overlap in leadership frameworks, examine a broader set of implementation outcomes, and examine conditions under which leadership impacts implementation.

TRIAL REGISTRATION

This review was not registered.

Massachusetts Justice Community Opioid Innovation Network (MassJCOIN)

A major driver of the U.S. opioid crisis is limited access to effective medications for opioid use disorder (MOUD) that reduce overdose risks. Traditionally, jails and prisons in the U.S. have not initiated or maintained MOUD for incarcerated individuals with OUD prior to their return to the community, which places them at high risk for fatal overdose. A 2018 law (Chapter 208) made Massachusetts (MA) the first state to mandate that five county jails deliver all FDA-approved MOUDs (naltrexone [NTX], buprenorphine [BUP], and methadone). Chapter 208 established a 4-year pilot program to expand access to all FDA-approved forms of MOUD at five jails, with two more MA jails voluntarily joining this initiative. The law stipulates that MOUD be continued for individuals receiving it prior to detention and be initiated prior to release among sentenced individuals where appropriate. The jails must also facilitate continuation of MOUD in the community on release. The Massachusetts Justice Community Opioid Innovation Network (MassJCOIN) partnered with these seven diverse jails, the MA Department of Public Health, and community treatment providers to conduct a Type 1 hybrid effectiveness-implementation study of Chapter 208. We will: (1) Perform a longitudinal treatment outcome study among incarcerated individuals with OUD who receive NTX, BUP, methadone, or no MOUD in jail to examine postrelease MOUD initiation, engagement, and retention, as well as fatal and nonfatal opioid overdose and recidivism; (2) Conduct an implementation study to understand systemic and contextual factors that facilitate and impede delivery of MOUDs in jail and community care coordination, and strategies that optimize MOUD delivery in jail and for coordinating care with community partners; (3) Calculate the cost to the correctional system of implementing MOUD in jail, and conduct an economic evaluation from state policy-maker and societal perspectives to compare the value of MOUD prior to release from jail to no MOUD among matched controls. MassJCOIN made significant progress during its first six months until the COVID-19 pandemic began in March 2020. Participating jail sites restricted access for nonessential personnel, established other COVID-19 mitigation policies, and modified MOUD programming. MassJCOIN adapted research activities to this new reality in an effort to document and account for the impacts of COVID-19 in relation to each aim. The goal remains to produce findings with direct implications for policy and practice for OUD in criminal justice settings.

Physical Activity and Cancer Care in the Atlantic Canadian Provinces: an Examination of Provider Beliefs, Practices, Resources, Barriers, and Enablers

Despite the well-established benefits of physical activity for cancer survivors, the vast majority of survivors are not sufficiently active to reap these benefits. While cancer-specific physical activity guidelines exist, it remains unclear whether there are sufficient resources to support these recommendations. The purpose of this qualitative study was to describe the available cancer-specific physical activity programs for cancer survivors in Atlantic Canada and explore barriers and enablers to program implementation. Interviews were conducted with a purposefully selected sample of oncology healthcare professionals, administrators, and cancer-specific physical activity program leaders to examine the attitudes and practices of key stakeholders with respect to physical activity and cancer-specific programming. Thirty participants, including 7 oncologists, 7 nurses, 6 allied healthcare professionals, 5 administrators, and 5 program leaders, completed an interview. Three over-arching themes emerged, including (1) knowledge, attitudes and need for physical activity; (2) implementation barriers; and (3) implementation enablers. The results of this study suggest that cancer survivors in Atlantic Canada may require additional resources and support with respect to physical activity throughout their cancer care journey.

Determinants of Evidence-based Practice Uptake in Rural Intensive Care Units. A Mixed Methods Study

Rationale: Evidence-based practices promote quality care for intensive care unit patients but chronic evidence-to-practice gaps limit their reach.Objectives: To characterize key determinants of evidence-based practice uptake in the rural intensive care setting.Methods: A parallel convergent mixed methods design was used with six hospitals receiving a quality improvement intervention. Guided by implementation science principles, we identified barriers and facilitators to uptake using clinician surveys (N = 90), key informant interviews (N = 14), and an implementation tracking log. Uptake was defined as completion of eight practice change steps within 12 months. After completing qualitative and quantitative data analyses for each hospital, site, staff, and program delivery factors were summarized within and across hospitals to identify patterns by uptake status.Results: At the site level, although structural characteristics (hospital size, intensivist staffing) did not vary by uptake status, interviews highlighted variability in staffing patterns and culture that differed by uptake status. At the clinician team level, readiness and self-efficacy were consistently high across sites at baseline with time and financial resources endorsed as primary barriers. However, interviews highlighted that as initiatives progressed, differences across sites in attitudes and ownership of change were key uptake influences. At the program delivery level, mixed methods data highlighted program engagement and leadership variability by uptake status. Higher uptake sites had better training attendance; more program activities completed; and a stable, engaged, collaborative nurse and physician champion team.Conclusions: Results provide an understanding of the multiple dynamic influences on different patterns of evidence-based practice uptake and the importance of implementation support strategies to accelerate uptake in the intensive care setting.

A systematic review of empirical studies examining mechanisms of implementation in health

BACKGROUND

Understanding the mechanisms of implementation strategies (i.e., the processes by which strategies produce desired effects) is important for research to understand why a strategy did or did not achieve its intended effect, and it is important for practice to ensure strategies are designed and selected to directly target determinants or barriers. This study is a systematic review to characterize how mechanisms are conceptualized and measured, how they are studied and evaluated, and how much evidence exists for specific mechanisms.

METHODS

We systematically searched PubMed and CINAHL Plus for implementation studies published between January 1990 and August 2018 that included the terms "mechanism," "mediator," or "moderator." Two authors independently reviewed title and abstracts and then full texts for fit with our inclusion criteria of empirical studies of implementation in health care contexts. Authors extracted data regarding general study information, methods, results, and study design and mechanisms-specific information. Authors used the Mixed Methods Appraisal Tool to assess study quality.

RESULTS

Search strategies produced 2277 articles, of which 183 were included for full text review. From these we included for data extraction 39 articles plus an additional seven articles were hand-entered from only other review of implementation mechanisms (total = 46 included articles). Most included studies employed quantitative methods (73.9%), while 10.9% were qualitative and 15.2% were mixed methods. Nine unique versions of models testing mechanisms emerged. Fifty-three percent of the studies met half or fewer of the quality indicators. The majority of studies (84.8%) only met three or fewer of the seven criteria stipulated for establishing mechanisms.

CONCLUSIONS

Researchers have undertaken a multitude of approaches to pursue mechanistic implementation research, but our review revealed substantive conceptual, methodological, and measurement issues that must be addressed in order to advance this critical research agenda. To move the field forward, there is need for greater precision to achieve conceptual clarity, attempts to generate testable hypotheses about how and why variables are related, and use of concrete behavioral indicators of proximal outcomes in the case of quantitative research and more directed inquiry in the case of qualitative research.

A systematic review of empirical studies examining mechanisms of implementation in health

BACKGROUND

Understanding the mechanisms of implementation strategies (i.e., the processes by which strategies produce desired effects) is important for research to understand why a strategy did or did not achieve its intended effect, and it is important for practice to ensure strategies are designed and selected to directly target determinants or barriers. This study is a systematic review to characterize how mechanisms are conceptualized and measured, how they are studied and evaluated, and how much evidence exists for specific mechanisms.

METHODS

We systematically searched PubMed and CINAHL Plus for implementation studies published between January 1990 and August 2018 that included the terms "mechanism," "mediator," or "moderator." Two authors independently reviewed title and abstracts and then full texts for fit with our inclusion criteria of empirical studies of implementation in health care contexts. Authors extracted data regarding general study information, methods, results, and study design and mechanisms-specific information. Authors used the Mixed Methods Appraisal Tool to assess study quality.

RESULTS

Search strategies produced 2277 articles, of which 183 were included for full text review. From these we included for data extraction 39 articles plus an additional seven articles were hand-entered from only other review of implementation mechanisms (total = 46 included articles). Most included studies employed quantitative methods (73.9%), while 10.9% were qualitative and 15.2% were mixed methods. Nine unique versions of models testing mechanisms emerged. Fifty-three percent of the studies met half or fewer of the quality indicators. The majority of studies (84.8%) only met three or fewer of the seven criteria stipulated for establishing mechanisms.

CONCLUSIONS

Researchers have undertaken a multitude of approaches to pursue mechanistic implementation research, but our review revealed substantive conceptual, methodological, and measurement issues that must be addressed in order to advance this critical research agenda. To move the field forward, there is need for greater precision to achieve conceptual clarity, attempts to generate testable hypotheses about how and why variables are related, and use of concrete behavioral indicators of proximal outcomes in the case of quantitative research and more directed inquiry in the case of qualitative research.

Testing a theory of strategic implementation leadership, implementation climate, and clinicians' use of evidence-based practice: a 5-year panel analysis

BACKGROUND

Implementation theory suggests that first-level leaders, sometimes referred to as middle managers, can increase clinicians' use of evidence-based practice (EBP) in healthcare settings by enacting specific leadership behaviors (i.e., proactive, knowledgeable, supportive, perseverant with regard to implementation) that develop an EBP implementation climate within the organization; however, longitudinal and quasi-experimental studies are needed to test this hypothesis.

METHODS

Using data collected at three waves over a 5-year period from a panel of 30 outpatient children's mental health clinics employing 496 clinicians, we conducted a quasi-experimental difference-in-differences study to test whether within-organization change in implementation leadership predicted within-organization change in EBP implementation climate, and whether change in EBP implementation climate predicted within-organization change in clinicians' use of EBP. At each wave, clinicians reported on their first-level leaders' implementation leadership, their organization's EBP implementation climate, and their use of both EBP and non-EBP psychotherapy techniques for childhood psychiatric disorders. Hypotheses were tested using econometric two-way fixed effects regression models at the organization level which controlled for all stable organizational characteristics, population trends in the outcomes over time, and time-varying covariates.

RESULTS

Organizations that improved from low to high levels of implementation leadership experienced significantly greater increases in their level of EBP implementation climate (d = .92, p = .017) and within-organization increases in implementation leadership accounted for 11% of the variance in improvement in EBP implementation climate beyond all other covariates. In turn, organizations that improved from low to high levels of EBP implementation climate experienced significantly greater increases in their clinicians' average EBP use (d = .55, p = .007) and within-organization improvement in EBP implementation climate accounted for 14% of the variance in increased clinician EBP use. Mediation analyses indicated that improvement in implementation leadership had a significant indirect effect on clinicians' EBP use via improvement in EBP implementation climate (d = .26, 95% CI [.02 to .59]).

CONCLUSIONS

When first-level leaders increase their frequency of implementation leadership behaviors, organizational EBP implementation climate improves, which in turn contributes to increased EBP use by clinicians. Trials are needed to test strategies that target this implementation leadership-EBP implementation climate mechanism.