Implementing complex innovations: factors influencing middle manager support

Understanding Implementation of Evidence-Based Interventions to Address Human Papillomavirus Vaccination: Qualitative Perspectives of Middle Managers

Engaging individuals in middle management positions (eg, nurse or clinic managers) could facilitate implementation of evidence-based interventions (EBIs) to improve uptake of human papillomavirus (HPV) vaccination. Our goal was to understand middle managers' role in and perspectives on implementation of EBIs for HPV vaccination. We conducted qualitative interviews with middle managers in pediatric and family practice clinics. We used constructs from the Consolidated Framework for Implementation Research (CFIR) to design the interview guide and as a coding framework. Participants (n = 19) reported overseeing implementation related to HPV vaccination. Across interviews, CFIR inner setting constructs (eg, structural characteristics and implementation climate) were identified as being both barriers and facilitators. As evidenced in this study, middle managers have a deep understanding of organizational factors, and they have the ability to facilitate implementation efforts related to HPV vaccination. Future efforts could focus on engaging middle managers and leveraging their expertise and understanding of barriers and facilitators.

Facilitators and barriers to the implementation of new critical care practices during COVID-19: a multicenter qualitative study using the Consolidated Framework for Implementation Research (CFIR)

BACKGROUND

The COVID-19 pandemic produced unprecedented demands and rapidly changing evidence and practices within critical care settings. The purpose of this study was to identify factors and strategies that hindered and facilitated effective implementation of new critical care practices and policies in response to the pandemic.

METHODS

We used a cross-sectional, qualitative study design to conduct semi-structured in-depth interviews with critical care leaders across the United States. The interviews were audio-taped and professionally transcribed verbatim. Guided by the Consolidated Framework for Implementation Research (CFIR), three qualitative researchers used rapid analysis methods to develop relevant codes and identify salient themes.

RESULTS

Among the 17 hospitals that agreed to participate in this study, 31 clinical leaders were interviewed. The CFIR-driven rapid analysis of the interview transcripts generated 12 major themes, which included six implementation facilitators (i.e., factors that promoted the implementation of new critical care practices) and six implementation barriers (i.e., factors that hindered the implementation of new critical care practices). These themes spanned the five CFIR domains (Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals, and Process) and 11 distinct CFIR constructs. Salient facilitators to implementation efforts included staff resilience, commitment, and innovation, which were supported through collaborative feedback and decision-making mechanisms between leadership and frontline staff. Major identified barriers included lack of access to reliable and transferable information, available resources, uncollaborative leadership and communication styles.

CONCLUSIONS

Through applying the CFIR to organize and synthesize our qualitative data, this study revealed important insights into implementation determinants that influenced the uptake of new critical care practices during COVID-19. As the pandemic continues to burden critical care units, clinical leaders should consider emulating the effective change management strategies identified. The cultivation of streamlined, engaging, and collaborative leadership and communication mechanisms not only supported implementation of new care practices across sites, but it also helped reduce salient implementation barriers, particularly resource and staffing shortages. Future critical care implementation studies should seek to capitalize on identified facilitators and reduce barriers.

How to fall into a new routine: factors influencing the implementation of an admission and discharge programme in hospitals and general practices

INTRODUCTION

The VESPEERA programme is a multifaceted programme to enhance information transfer between general practice and hospital across the process of hospital admission, stay and discharge. It was implemented in 7 hospitals and 72 general practices in Southern Germany. Uptake was heterogeneous and overall low. A process evaluation aimed at identifying factors associated with the implementation of the VESPEERA programme.

METHODS

This was a qualitative study using semi-structured interviews in a purposeful sample of health workers in hospitals and general practices in the VESPEERA programme. Qualitative framework analysis using the Consolidated Framework for Implementation Research was performed and revealed the topic of previous and new routines to be protruding. Inductive content analysis was used for in-depth examination of stages in the process of staying in a previous or falling into a new routines.

RESULTS

Thirty-six interviews were conducted with 17 participants from general practices and 19 participants from hospitals. The interviewees were in different stages of the implementation process at the time of the interviews. Four stages were identified: Stage 1,'Previous routine and tension for change', describes the situation in which VESPEERA was to be implemented and the factors leading to the decision to participate. In stage 2,'Adoption of the VESPEERA programme', factors that influenced whether individuals decided to employ the innovation are relevant. Stage 3 comprises 'Determinants for falling into and staying in the new VESPEERA-routine' relates to actual implementation and finally, in stage 4, the participants reflect on the success of the implementation.

CONCLUSIONS

The individuals and organisations participating in the VESPEERA programme were in different stages of a process from the previous to the new routine, which were characterised by different determinants of implementation. In all stages, organisational factors were main determinants of implementation, but different factors emerged in different implementation stages. A low distinction between decision-making power and executive, as well as available resources, were beneficial for the implementation of the innovation.

TRIAL REGISTRATION

DRKS00015183 on DRKS / Universal Trial Number (UTN): U1111-1218-0992.

Leadership in the Context of Digital Health Services: A Concept Analysis

AIM

To define and clarify the concept of leadership in the context of digital health services using Walker's and Avant's concept analysis model.

BACKGROUND

Conceptualizing leadership in the context of digital health services is needed to deliver higher quality services and advance research.

METHOD

Searches were conducted of MEDLINE (Ovid), Scopus, CINAHL (EBSCO), and ProQuest (ABI/INFORM). Empirical articles were included if they reported attributes, antecedents, or consequences of leadership in the study context. A total of 4,037 references were identified; 23 were included.

RESULTS

Leadership attributes concerned leaders' behavior, roles, and qualities. Antecedents concerned informatics skills and competence, information and tools, understanding care systems and their complexity, and education. Consequences related to organization, professionals, and patient and care.

CONCLUSION

Based on our results, the term 'e-leadership' should be more widely utilized in nursing practice and research.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse leaders need to be strong leaders; they need to be visionary and use strategic thinking to develop existing and new digital solutions. By becoming e-leaders, nurse leaders may increase the successful development and implementation of eHealth, and benefit clinicians and patients.

Factors contributing to innovation readiness in health care organizations: a scoping review

Background

Increasing innovation readiness of healthcare organizations is necessary to meet upcoming challenges, including population aging, staff shortages and reduced funding. Health care organizations differ in the extent to which they are innovation ready. This review aims to clarify the concept of innovation readiness and identify which factors contribute to innovation readiness in health care organizations.

Methods

A scoping review was conducted based on the framework from Arksey and O’Malley. PubMed/MEDLINE, CINAHL and Web of Science were searched for studies that (a) aimed to contribute to scientific knowledge about innovation readiness of health care organizations, (b) were peer-reviewed, (c) reported empirical data and (d) were written in English, Dutch or German. Factors researched in the included studies were bundled into 4 overarching main factors and 10 sub-factors.

Results

Of the 6,208 studies identified, 44 were included. The majority (n = 36) of the studies had been conducted since 2011 and almost half of the studies (n = 19) were performed in hospitals. Of the 44 studies, 21 researched factors contributing to innovation readiness in the implementation stage of the innovation process. The authors used a variety of words and descriptions addressing innovation readiness, with hardly any theoretical frameworks for innovation readiness presented. Four main factors and 10 sub-factors contributing to the innovation readiness of health care organizations were summarized: strategic course for innovation, climate for innovation, leadership for innovation and commitment to innovation. Climate for innovation (n = 16) was studied the most and individual commitment to innovation (n = 6) was the least studied.

Conclusion

Our study identified four main factors contributing to the innovation readiness of health care organizations. Research into innovation readiness of health care organizations is a rather new field. Future research could be directed towards defining the concept of innovation readiness and the development of a framework for innovation readiness. More understanding of the interplay of factors contributing to innovation readiness in all stages of the innovation process and in diverse health care settings can support health care managers to structurally embed innovation. This review contributes to the first stage of theory building on factors contributing to innovation readiness of health care organizations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08185-x.

Assessing readiness to implement patient navigator programs in Toronto, Canada

OBJECTIVE

To explore factors influencing the implementation of patient navigator programs within a hospital for seniors with complex care needs.

METHODS

A qualitative descriptive design using in-depth interviews was conducted. Participant interviews were conducted in Toronto, Ontario between September 2020 and February 2021. Data were analysed using thematic analysis.

RESULTS

Thirty-five semi-structured interviews were conducted with 38 participants from a large urban hospital (n = 21) and community healthcare organizations (n = 17), including organizational leaders, and acute care and rehabilitation providers. Follow-up interviews occurred with 16 participants (7 from the community and nine from the hospital). This study identified five key factors influencing organizational readiness for successful implementation of a patient navigator program for seniors with complex conditions, which included: (a) vision from senior leadership, (b) technological infrastructure, (c) existing hospital-community partnerships, (d) well-established process for referrals, and (e) staff capacity. The overarching theme of communication was also identified.

CONCLUSIONS

The findings of this study provide a better understanding of hospital and community professionals' needs and challenges when implementing patient navigator programs for seniors with complex care conditions. There are a number of factors that influence an organization's readiness for program uptake and delivery, with the need for clear communication being paramount. Further research to test the effects of readiness on successful implementation outcomes is warranted.

Person-Centered Care in Nursing Homes: Potential of Complementary and Alternative Approaches and Their Challenges

A person-centered approach to care shifts the mind-set of care partners from a traditional medical model to a social model in managing chronic conditions. Using a qualitative descriptive approach, this study examines the barriers and facilitators to the implementation of person-centered care (PCC) and how the integration of complementary and alternative approaches (CAA) has the potential to improve residents' quality of life in nursing homes (NHs). Findings indicate that NHs offer a wide range of engagement activities, but these activities are not purposefully integrated into a person-centered plan of care. Factors such as turnover, "working short," supervisor support, and rising resident care needs make it challenging to implement PCC in NHs. This knowledge of the landscape of activities will help us identify and improve strategies for supporting residents at a deeper, more meaningful level. CAA has the potential to be therapeutic for residents if integrated into collaborative approaches to care.

Navigating change - managers' experience of implementation processes in disability health care: a qualitative study

Background

Effective implementation processes play a central role in health care organizations and affect the care of patients. Managers are pivotal in facilitating the use of new practices, but their experience and how it affects the implementation outcome are still largely unknown. In the field of disability health care in particular, managers experiences have scarcely been investigated. Therefore, the aim of this study is to explore managers’ experiences of the implementation process when transferring new practices into disability health care settings.

Methods

Semi-structured individual telephone interviews were conducted with managers at disability health care organizations in four administrative regions in central Sweden. A total of 23 managers with formal managerial responsibility from both public and private health care were strategically selected to be interviewed. The interviews were analysed using reflexive thematic analysis with an inductive approach.

Results

The analysis resulted in two themes about factors influencing the implementation process: firstly, Contextual factors set the agenda for what can be achieved, which highlighted aspects that hinder or enable the implementation process, such as internal and external conditions, the workplace culture, the employees and managers’ attitudes and openness to change: secondly, Leadership in the winds of change, which described the challenges of balancing managerial tasks with leading the change, and the importance of a leadership that involves the participation of the employees.

Conclusions

This study explored how and to what extent managers address and manage the implementation process and the many associated challenges. The findings highlight the importance of leadership support and organizational structure in order to transfer new practices into the work setting, and to encourage an organizational culture for leading change that promotes positive outcomes. We suggest that identifying strategies by focusing on contextual factors and on aspects of leadership will facilitate implementation processes.

Trial registration

The SWAN (Structured Water Dance Intervention) study was retrospectively registered on April 9, 2019 and is available online at ClinicalTrials.gov (ID: NCT03908801).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06570-6.

Identifying actionable strategies: using Consolidated Framework for Implementation Research (CFIR)-informed interviews to evaluate the implementation of a multilevel intervention to improve colorectal cancer screening

BACKGROUND

Many evidence-based interventions (EBIs) found to be effective in research studies often fail to translate into meaningful patient outcomes in practice. The purpose of this study was to identify facilitators and barriers that affect the implementation of three EBIs to improve colorectal cancer (CRC) screening in an urban federally qualified health center (FQHC) and offer actionable recommendations to improve future implementation efforts.

METHODS

We conducted 16 semi-structured interviews guided by the Consolidation Framework for Implementation Research (CFIR) to describe diverse stakeholders' implementation experience. The interviews were conducted in the participant's clinic, audio-taped, and professionally transcribed for analysis.

RESULTS

We used the five CFIR domains and 39 constructs and subconstructs as a coding template to conduct a template analysis. Based on experiences with the implementation of three EBIs, stakeholders described barriers and facilitators related to the intervention characteristics, outer setting, and inner setting. Implementation barriers included (1) perceived burden and provider fatigue with EHR (Electronic Health Record) provider reminders, (2) unreliable and ineffectual EHR provider reminders, (3) challenges to providing health care services to diverse patient populations, (4) lack of awareness about CRC screening among patients, (5) absence of CRC screening goals, (6) poor communication on goals and performance, and (7) absence of printed materials for frontline implementers to educate patients. Implementation facilitators included (1) quarterly provider assessment and feedback reports provided real-time data to motivate change, (2) integration with workflow processes, (3) pressure from funding requirement to report quality measures, (4) peer pressure to achieve high performance, and (5) a culture of teamwork and patient-centered mentality.

CONCLUSIONS

The CFIR can be used to conduct a post-implementation formative evaluation to identify barriers and facilitators that influenced the implementation. Furthermore, the CFIR can provide a template to organize research data and synthesize findings. With its clear terminology and meta-theoretical framework, the CFIR has the potential to promote knowledge-building for implementation. By identifying the contextual determinants, we can then determine implementation strategies to facilitate adoption and move EBIs to daily practice.

Effects on staff outcomes and process evaluation of the educating nursing staff effectively (TENSE) program for managing challenging behavior in nursing home residents with dementia: A cluster-randomized controlled trial

BACKGROUND

Challenging behavior is prevalent in people with dementia residing in nursing homes and places a high burden on the nursing staff of dementia special care units. This study evaluates an educational program for nursing staff for managing challenging behavior: The Educating Nursing Staff Effectively (TENSE) program. This program can be tailored to care organizations' wishes and needs and combines various learning styles.

OBJECTIVE

The aim of this cluster-randomized controlled trial was to examine the short-term (3 months) and long-term (9 months) effects of the TENSE training program on experienced stress, work contentment, and stress reactions at work in nursing staff working in dementia special care units.

DESIGN

Cluster-randomized controlled trial.

METHODS

Nursing staff members of 18 dementia special care units within nine nursing homes from different Netherlands regions were randomized into an intervention (n = 168) or control (n = 129) group. The TENSE program consisted of a three-day training course and two follow-up sessions after three and six months, respectively. The primary outcome was stress experienced by nursing staff measured with the Utrecht Burnout Scale - C. Secondary outcomes were work contentment and stress reactions at work. Furthermore, process evaluation data on the reach of and compliance with the program and the program's feasibility and relevance were collected. Data were collected between November 2012 and November 2014.

RESULTS

In general, the participants appreciated the quality and relevance of the TENSE training and evaluated the content of the training as beneficial. The TENSE training had no effect on the components of experienced stress, i.e., emotional exhaustion (p = 0.751), depersonalization (p = 0.701), and personal accomplishment (p = 0.182). Furthermore, no statistically significant effects of the intervention on work contentment and stress reactions at work were found.

CONCLUSIONS

The TENSE training program did not have an effect on experienced stress, work contentment, nor stress reactions at work of nursing staff working in dementia special care units. In future studies, more focus on practicing new skills seems needed.

TRIAL REGISTRATION

NTR (Dutch Trial Registration) number NTR3620.

Redesigning the Role of Medical Assistants in Primary Care: Challenges and Strategies During Implementation

Efforts to reform primary care increasingly focus on redesigning care in ways that utilize nonprovider staff such as medical assistants (MAs), but the implementation of MA role redesign efforts remains understudied in the U.S. health care literature. This article draws on rich, longitudinal case study data collected from four health care systems across the United States to examine critical challenges in the planning, implementation, and early sustainment of MA role redesign efforts in primary care. During the planning period, challenges included recruitment of highly trained MAs, compliance with organizational and state regulations regarding MA scope of practice, provision of consistent training across primary care clinics, and creation of career ladders that provided tiered compensation for MAs. During active implementation, challenges included provider training and preventing MA burnout. Strategies for addressing challenges in MA role redesign efforts are discussed, as well as early sustainment of program practices and organizational policies.

Healthcare middle managers' experiences of developing capacity and capability: a systematic review and meta-synthesis

BACKGROUND

Healthcare middle managers play a central role in reducing harm, improving patient safety, and strengthening the quality of healthcare. The aim of this systematic review was to identify the present knowledge and critically discuss how healthcare middle managers experienced to develop the capacity and capability for leadership in a healthcare system characterized by high complexity.

METHODS

This comprehensive systematic review provided evidence of healthcare middle managers' experiences in developing the capacity and capability for leadership in public healthcare. The three-step literature search was based on six databases and led by a PICo question. The review had a critical hermeneutic perspective and was based on an a priori published, protocol. The methods were inspired by the Joanna Briggs Institute and techniques from Kvale and Brinkmann. The results were illustrated by effect size, inspired by Sandelowski and Barroso.

RESULTS

Twenty-three studies from four continents and multiple contexts (hospitals and municipal healthcare) published from January 2005-February 2019 were included. Based on experiences from 482 healthcare middle managers, 2 main themes, each with 2 subthemes, were identified, and from these, a meta-synthesis was developed: Healthcare middle managers develop capacity and capability through personal development processes empowered by context. The main themes included the following: 1. personal development of capacity and capability and 2. a need for contextual support. From a critical hermeneutic perspective, contrasts were revealed between how healthcare middle managers experienced the development of their capacity and capability and what they experienced as their typical work situation.

CONCLUSIONS

This review provides evidence of the need for a changed approach in healthcare in relation to criticisms of present organizational structures and management methods and suggestions for how to strengthen healthcare middle managers' capacity and capability for leadership in a healthcare system characterized by high complexity. Evidence of how leadership development affected the clinical context and, thus, the quality of healthcare was found to be a field requiring further research.

PROSPERO REGISTRATION NUMBER

CRD42018084670.

Middle managers' role in implementing evidence-based practices in healthcare: a systematic review

BACKGROUND

Middle managers are in a unique position to promote the implementation of evidence-based practices (EBPs) in healthcare organizations, yet knowledge of middle managers' role in implementation and determinants (e.g., individual-, organizational-, and system-level factors) which influence their role remains fractured, spanning decades and disciplines. To synthesize understanding, we undertook a systematic review of studies of middle managers' role in healthcare EBP implementation and determinants of that role.

METHODS

We searched MEDLINE/PubMed and Business Source Complete (Ebsco) for literature on middle managers' role in healthcare EBP implementation and its determinants. We abstracted data from records that met inclusion criteria (i.e., written in English, peer-reviewed, and reporting either a protocol or results of an empirical study) into a matrix for analysis. We summarized categorical variables using descriptive statistics. To analyze qualitative data, we used a priori codes and then allowed additional themes to emerge.

RESULTS

One hundred five records, spanning across several countries and healthcare settings and relating to a range of EBPs, met our inclusion criteria. Studies of middle managers' role in healthcare EBP implementation and its determinants substantially increased from 1996 to 2015. Results from included studies suggest that middle managers shape implementation climate in addition to fulfilling the four roles hypothesized in extant theory of middle managers' role in implementation. However, extant studies offered little understanding of determinants of middle managers' role.

CONCLUSIONS

Our findings suggest that middle managers may play an important role in facilitating EBP implementation. Included studies offered little understanding regarding the relative importance of various roles, potential moderators of the relationship between middle managers' roles and EBP implementation, or determinants of middle managers' role in EBP implementation. Future studies should seek to understand determinants and moderators of middle managers' role. Clearer understanding may facilitate the translation of evidence into practice.

Factors influencing middle managers' commitment to the implementation of innovations in cancer care

OBJECTIVE

To identify and illuminate influences on middle managers' commitment to innovation implementation.

METHODS

A qualitative study was conducted, employing the methods of grounded theory. Semi-structured interviews were used to collect data from middle managers (n = 15) in Nova Scotia and New Brunswick, Canada. Data were collected and analysed concurrently, using an inductive constant comparative approach. Data collection and analysis continued until theoretical saturation was reached.

RESULTS

The data revealed middle managers contemplate two central issues in terms of their commitment to implementation, that is whether or not they fully engage in and support the implementation of a particular innovation. These issues are (1) ease of implementation and (2) potential benefit for patients. Middle managers' views and expectations related to ease of implementation are influenced by available resources, fit with setting, and stakeholder buy-in. Their views on patient benefit are influenced by external evidence of benefit and local gaps in care.

CONCLUSIONS

These findings provide further insight into the factors that influence middle managers' commitment to innovation implementation, and how middle managers consider these factors in the context of their work settings.

Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review

BACKGROUND

Organizational contextual features have been recognized as important determinants for implementing evidence-based practices across healthcare settings for over a decade. However, implementation scientists have not reached consensus on which features are most important for implementing evidence-based practices. The aims of this review were to identify the most commonly reported organizational contextual features that influence the implementation of evidence-based practices across healthcare settings, and to describe how these features affect implementation.

METHODS

An integrative review was undertaken following literature searches in CINAHL, MEDLINE, PsycINFO, EMBASE, Web of Science, and Cochrane databases from January 2005 to June 2017. English language, peer-reviewed empirical studies exploring organizational context in at least one implementation initiative within a healthcare setting were included. Quality appraisal of the included studies was performed using the Mixed Methods Appraisal Tool. Inductive content analysis informed data extraction and reduction.

RESULTS

The search generated 5152 citations. After removing duplicates and applying eligibility criteria, 36 journal articles were included. The majority (n = 20) of the study designs were qualitative, 11 were quantitative, and 5 used a mixed methods approach. Six main organizational contextual features (organizational culture; leadership; networks and communication; resources; evaluation, monitoring and feedback; and champions) were most commonly reported to influence implementation outcomes in the selected studies across a wide range of healthcare settings.

CONCLUSIONS

We identified six organizational contextual features that appear to be interrelated and work synergistically to influence the implementation of evidence-based practices within an organization. Organizational contextual features did not influence implementation efforts independently from other features. Rather, features were interrelated and often influenced each other in complex, dynamic ways to effect change. These features corresponded to the constructs in the Consolidated Framework for Implementation Research (CFIR), which supports the use of CFIR as a guiding framework for studies that explore the relationship between organizational context and implementation. Organizational culture was most commonly reported to affect implementation. Leadership exerted influence on the five other features, indicating it may be a moderator or mediator that enhances or impedes the implementation of evidence-based practices. Future research should focus on how organizational features interact to influence implementation effectiveness.

Integrating: A managerial practice that enables implementation in fragmented health care environments

BACKGROUND

How some organizations improve while others remain stagnant is a key question in health care research. Studies identifying how organizations can implement improvement despite barriers are needed, particularly in primary care.

PURPOSES

This inductive qualitative study examines primary care clinics implementing improvement efforts in order to identify mechanisms that enable implementation despite common barriers, such as lack of time and fragmentation across stakeholder groups.

METHODOLOGY

Using an embedded multiple case study design, we leverage a longitudinal data set of field notes, meeting minutes, and interviews from 16 primary care clinics implementing improvement over 15 months. We segment clinics into those that implemented more versus those that implemented less, comparing similarities and differences. We identify interpersonal mechanisms promoting implementation, develop a conceptual model of our key findings, and test the relationship with performance using patient surveys conducted pre-/post-implementation.

FINDINGS

Nine clinics implemented more successfully over the study period, whereas seven implemented less. Successfully implementing clinics exhibited the managerial practice of integrating, which we define as achieving unity of effort among stakeholder groups in the pursuit of a shared and mutually developed goal. We theorize that integrating is critical in improvement implementation because of the fragmentation observed in health care settings, and we extend theory about clinic managers' role in implementation. We identify four integrating mechanisms that clinic managers enacted: engaging groups, bridging communication, sensemaking, and negotiating. The mean patient survey results for integrating clinics improved by 0.07 units over time, whereas the other clinics' survey scores declined by 0.08 units on a scale of 5 (p = .02).

PRACTICE IMPLICATIONS

Our research explores an understudied element of how clinics can implement improvement despite barriers: integrating stakeholders within and outside the clinic into the process. It provides clinic managers with an actionable path for implementing improvement.

The Role of Managers in Employee Wellness Programs: A Mixed-Methods Study

Purpose:

The purpose of this study is to evaluate managers’ barriers and facilitators to supporting employee participation in the Washington State Wellness program.

Design:

Exploratory sequential mixed methods.

Setting:

Four Washington State agencies located in Olympia and Tumwater, Washington.

Participants:

State employees in management positions (executive, middle, and line), whose job includes supervision of subordinates and responsibility for the performance and conduct of a subunit or group.

Methods:

We interviewed 23 managers and then used the results to create a survey that was fielded to all managers at the 4 agencies. The survey response rate was 65% (n = 607/935).

Analysis:

We used qualitative coding techniques to analyze interview transcripts and descriptive statistics to summarize survey data. We used the Total Worker Health framework to organize our findings and conclusions.

Results:

Managers support the wellness program, but they also face challenges with accommodating employees’ participation due to workload, scheduling inflexibility, and self-efficacy to discuss wellness with direct reports. About half the managers receive support from the manager above them, and most have not received training on the wellness program.

Conclusion:

Our findings point to several strategies that can strengthen managers’ role in supporting the wellness program: the provision of training, targeted messages, formal expectations, and encouragement (from the manager above) to support employees’ participation.

Managers’ Support for Employee Wellness Programs: An Integrative Review

Objective:

The aim of this integrative literature review is to synthesize the existing evidence regarding managers’ support for employee wellness programs.

Data Source:

The search utilized multiple electronic databases and libraries.

Study Inclusion and Exclusion Criteria:

Inclusion criteria comprised peer-reviewed research published in English, between 1990 and 2016, and examining managers’ support in the context of a worksite intervention. The final sample included 21 articles for analysis.

Data Extraction:

Two researchers extracted and described results from each of the included articles using a content analysis.

Data Synthesis:

Two researchers independently rated the quality of the included articles. Researchers synthesized data into a summary table by study design, sample, data collected, key findings, and quality rating.

Results:

Factors that may influence managers’ support include their organization’s management structure, senior leadership support, their expected roles, training on health topics, and their beliefs and attitudes toward wellness programs and employee health. Managers’ support may influence the organizational culture, employees’ perception of support, and employees’ behaviors.

Conclusions:

When designing interventions, health promotion practitioners and researchers should consider strategies that target senior, middle, and line managers’ support. Interventions need to include explicit measures of managers’ support as part of the evaluation plan.

What roles do middle managers play in implementation of innovative practices?

BACKGROUND

Middle managers play key roles in hospitals as the bridge between senior leaders and frontline staff. Yet relatively little research has focused on their role in implementing new practices.

PURPOSE

The aim of this study was to expand the understanding of middle managers' influence in organizations by looking at their activities through the lens of two complementary conceptual frameworks.

METHODOLOGY/APPROACH

We analyzed qualitative data from 17 Veterans Affairs Medical Centers with high and low potential to change organizational practices. We analyzed 98 interviews with staff ranging from senior leaders to frontline staff to identify themes within an a priori framework reflecting middle manager activities.

FINDINGS

Analyses yielded 14 emergent themes that allowed us to classify specific expressions of middle manager commitment to implementation of innovative practices (e.g., facilitate improvement innovation, garner staff buy-in). In comparing middle manager behaviors in high and low change potential sites, we found that most emergent themes were present in both groups. However, the activities and interactions described differed between the groups.

PRACTICE IMPLICATIONS

Middle managers can use the promising strategies identified by our analyses to guide and improve their effectiveness in implementing new practices. These strategies can also inform senior leaders striving to guide middle managers in those efforts.

Innovation Implementation in the Context of Hospital QI: Lessons Learned and Strategies for Success

In 1999, the Institute of Medicine reported that 98,000 people die each year due to medical errors. In the following years, the focus on hospital quality was intensified nationally, with policymakers providing evidence-based practice guidelines for improving health care quality. However, these innovations (evidence-based guidelines) that were being produced at policy levels were not translating to clinical practice at the hospital organizational level easily, and stark variations continued to persist, in the quality of health care. Circa 2009, nearly a decade after the release of the IOM report, the health care organizational literature began referring to this challenge as "innovation implementation failure" in health care organizations (HCOs), ie, failure to implement an evidence-based practice that is new to a HCO. This stream of literature drew upon management research to explain why innovation implementation failure occurs in HCOs and what could be done to prevent it. This paper conducts an integrative review of the literature on "innovation implementation" in hospitals and health systems over the last decade, since the spotlight was cast on "innovation implementation failure" in HCOs. The review reveals that while some studies have retrospectively sought to identify the key drivers of innovation implementation, through surveys and interviews of practitioners (the "what"), other studies have prospectively sought to understand how innovation implementation occurs in hospitals and health systems (the "how"). Both make distinctive contributions to identifying strategies for success in innovation implementation. While retrospective studies have helped identify the key drivers of innovation implementation, prospective studies have shed light on how these drivers could be attained, thereby helping to develop context-sensitive management strategies for success. The literature has called for more prospective research on the implementation and sustainability of health care innovations. This paper summarizes the lessons learned from the literature, discusses the relevance of management research on innovation implementation in HCOs, and identifies future research avenues.

Implementation in the midst of complexity: Using ethnography to study health care-associated infection prevention and control

BACKGROUND

Contextual factors associated with health care settings make reducing health care-associated infections (HAIs) a complex task. The aim of this article is to highlight how ethnography can assist in understanding contextual factors that support or hinder the implementation of evidence-based practices for reducing HAIs.

METHODS

We conducted a review of ethnographic studies specifically related to HAI prevention and control in the last 5 years (2012-2017).

RESULTS

Twelve studies specific to HAIs and ethnographic methods were found. Researchers used various methods with video-reflexive sessions used in 6 of the 12 studies. Ethnography was used to understand variation in data reporting, identify barriers to adherence, explore patient perceptions of isolation practices and highlight the influence of physical design on infection prevention practices. The term ethnography was used to describe varied research methods. Most studies were conducted outside the United States, and authors indicate insights gained using ethnographic methods (whether observations, interviews, or reflexive video recording) as beneficial to unraveling the complexities of HAI prevention.

CONCLUSIONS

Ethnography is well-suited for HAI prevention, especially video-reflexive ethnography, for activating patients and clinicians in infection control work. In this era of increasing pressure to reduce HAIs within complex work systems, ethnographic methods can promote understanding of contextual factors and may expedite translation evidence to practice.

Survey process quality: a question of healthcare manager approach

Purpose The purpose of this paper is to explore how healthcare first-line managers think about and act regarding workplace survey processes. Design/methodology/approach This interview study was performed at a hospital in south Sweden. First-line healthcare managers ( n=24) volunteered. The analysis was inspired by phenomenography, which aims to describe the ways in which different people experience a phenomenon. The phenomenon was a workplace health promotion (WHP) survey processes. Findings Four main WHP survey process approaches were identified among the managers: as a possibility, as a competition, as a work task among others and as an imposition. For each, three common subcategories emerged; how managers: stated challenges and support from hospital management; described their own work group and collaboration with other managers; and expressed themselves and their situation in their roles as first-line managers. Practical implications Insights into how hospital management can understand their first-line managers' motivation for survey processes and practical suggestions and how managers can work proactively at organizational, group and individual level are presented. Originality/value Usually these studies focus on those who should respond to a survey; not those who should run the survey process. Focusing on managers and not co-workers can lead to more committed and empowered managers and thereby success in survey processes.

Developing Leadership in Managers to Facilitate the Implementation of National Guideline Recommendations: A Process Evaluation of Feasibility and Usefulness

BACKGROUND

Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers' leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention's potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation.

METHODS

Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a four-month leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention.

RESULTS

Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation.

CONCLUSION

Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers' behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations.

Barriers to Implementing Evidence-Based Intrapartum Care: A Descriptive Exploratory Qualitative Study

BACKGROUND

Evidence based practice is an effective strategy to improve the quality of obstetric care. Identification of barriers to adaptation of evidence-based intrapartum care is necessary and crucial to deliver high quality care to parturient women.

OBJECTIVES

The current study aimed to explore barriers to adaptation of evidence-based intrapartum care from the perspective of clinical groups that provide obstetric care in Iran.

MATERIALS AND METHODS

This descriptive exploratory qualitative research was conducted from 2013 to 2014 in fourteen state medical training centers in Iran. Participants were selected from midwives, specialists, and residents of obstetrics and gynecology, with a purposive sample and snowball method. Data were collected through face-to-face semi-structured in-depth interviews and analyzed according to conventional content analysis.

RESULTS

Data analysis identified twenty subcategories and four main categories. Main categories included barriers were related to laboring women, persons providing care, the organization environment and health system.

CONCLUSIONS

The adoption of evidence based intrapartum care is a complex process. In this regard, identifying potential barriers is the first step to determine and apply effective strategies to encourage the compliance evidence based obstetric care and improves maternity care quality.

From strategy to action: how top managers' support increases middle managers' commitment to innovation implementation in health care organizations

BACKGROUND

Evidence suggests that top managers' support influences middle managers' commitment to innovation implementation. What remains unclear is how top managers' support influences middle managers' commitment. Results may be used to improve dismal rates of innovation implementation.

METHODS

We used a mixed-method sequential design. We surveyed (n = 120) and interviewed (n = 16) middle managers implementing an innovation intended to reduce health disparities in 120 U.S. health centers to assess whether top managers' support directly influences middle managers' commitment; by allocating implementation policies and practices; or by moderating the influence of implementation policies and practices on middle managers' commitment. For quantitative analyses, multivariable regression assessed direct and moderated effects; a mediation model assessed mediating effects. We used template analysis to assess qualitative data.

FINDINGS

We found support for each hypothesized relationship: Results suggest that top managers increase middle managers' commitment by directly conveying to middle managers that innovation implementation is an organizational priority (β = 0.37, p = .09); allocating implementation policies and practices including performance reviews, human resources, training, and funding (bootstrapped estimate for performance reviews = 0.09; 95% confidence interval [0.03, 0.17]); and encouraging middle managers to leverage performance reviews and human resources to achieve innovation implementation.

PRACTICE IMPLICATIONS

Top managers can demonstrate their support directly by conveying to middle managers that an initiative is an organizational priority, allocating implementation policies and practices such as human resources and funding to facilitate innovation implementation, and convincing middle managers that innovation implementation is possible using available implementation policies and practices. Middle managers may maximize the influence of top managers' support on their commitment by communicating with top managers about what kind of support would be most effective in increasing their commitment to innovation implementation.

Towards Effective Management in Psychiatric-Mental Health Nursing: The Dangers and Consequences of Micromanagement

Micromanagement refers to a management style that involves managers exercising control over team members, teams, and also organizations, particularly in relation to the minutiae or minor details of day-to-day operations. While there is no single reason why some managers may choose to micromanage, many micromanagers exhibit similar behavioral traits, a consequence of perfectionism and/or underlying insecurities. In the culture of high performance that characterizes many contemporary mental health contexts, micromanagement also provides one way by which teams can be driven to achieve targets. However, over time, micromanagement leads to reductions in staff morale, creativity, and productivity; and increases in staff turnover. This paper provides an overview of micromanagement, including points of consideration for managers interested in reflecting on their management styles, and strategies for mental health nurses who find themselves working for a micromanager.