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Williams NJ, Ehrhart MG, Aarons GA, Esp S, Sklar M, Carandang K, Vega NR, Brookman-Frazee L, Marcus SC. Improving measurement-based care implementation in youth mental health through organizational leadership and climate: a mechanistic analysis within a randomized trial. Implement Sci 2024; 19:29. [PMID: 38549122 PMCID: PMC10976812 DOI: 10.1186/s13012-024-01356-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/27/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Theory and correlational research indicate organizational leadership and climate are important for successful implementation of evidence-based practices (EBPs) in healthcare settings; however, experimental evidence is lacking. We addressed this gap using data from the WISDOM (Working to Implement and Sustain Digital Outcome Measures) hybrid type III effectiveness-implementation trial. Primary outcomes from WISDOM indicated the Leadership and Organizational Change for Implementation (LOCI) strategy improved fidelity to measurement-based care (MBC) in youth mental health services. In this study, we tested LOCI's hypothesized mechanisms of change, namely: (1) LOCI will improve implementation and transformational leadership, which in turn will (2) mediate LOCI's effect on implementation climate, which in turn will (3) mediate LOCI's effect on MBC fidelity. METHODS Twenty-one outpatient mental health clinics serving youth were randomly assigned to LOCI plus MBC training and technical assistance or MBC training and technical assistance only. Clinicians rated their leaders' implementation leadership, transformational leadership, and clinic implementation climate for MBC at five time points (baseline, 4-, 8-, 12-, and 18-months post-baseline). MBC fidelity was assessed using electronic metadata for youth outpatients who initiated treatment in the 12 months following MBC training. Hypotheses were tested using longitudinal mixed-effects models and multilevel mediation analyses. RESULTS LOCI significantly improved implementation leadership and implementation climate from baseline to follow-up at 4-, 8-, 12-, and 18-month post-baseline (all ps < .01), producing large effects (range of ds = 0.76 to 1.34). LOCI's effects on transformational leadership were small at 4 months (d = 0.31, p = .019) and nonsignificant thereafter (ps > .05). LOCI's improvement of clinic implementation climate from baseline to 12 months was mediated by improvement in implementation leadership from baseline to 4 months (proportion mediated [pm] = 0.82, p = .004). Transformational leadership did not mediate LOCI's effect on implementation climate (p = 0.136). Improvement in clinic implementation climate from baseline to 12 months mediated LOCI's effect on MBC fidelity during the same period (pm = 0.71, p = .045). CONCLUSIONS LOCI improved MBC fidelity in youth mental health services by improving clinic implementation climate, which was itself improved by increased implementation leadership. Fidelity to EBPs in healthcare settings can be improved by developing organizational leaders and strong implementation climates. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04096274. Registered September 18, 2019.
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Affiliation(s)
- Nathaniel J Williams
- Institute for the Study of Behavioral Health and Addiction, Boise State University, Boise, ID, USA.
- School of Social Work, Boise State University, Boise, ID, 83725, USA.
| | - Mark G Ehrhart
- Department of Psychology, University of Central Florida, Orlando, FL, USA
| | - Gregory A Aarons
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Susan Esp
- Institute for the Study of Behavioral Health and Addiction, Boise State University, Boise, ID, USA
- School of Social Work, Boise State University, Boise, ID, 83725, USA
| | - Marisa Sklar
- Department of Psychiatry, University of California, San Diego, CA, USA
| | | | - Nallely R Vega
- School of Social Work, Boise State University, Boise, ID, 83725, USA
| | | | - Steven C Marcus
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
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McLeman B, Gauthier P, Lester LS, Homsted F, Gardner V, Moore SK, Joudrey PJ, Saldana L, Cochran G, Harris JP, Hefner K, Chongsi E, Kramer K, Vena A, Ottesen RA, Gallant T, Boggis JS, Rao D, Page M, Cox N, Iandiorio M, Ambaah E, Ghitza U, Fiellin DA, Marsch LA. Implementing a pharmacist-integrated collaborative model of medication treatment for opioid use disorder in primary care: study design and methodological considerations. Addict Sci Clin Pract 2024; 19:18. [PMID: 38500166 PMCID: PMC10949656 DOI: 10.1186/s13722-024-00452-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Pharmacists remain an underutilized resource in the treatment of opioid use disorder (OUD). Although studies have engaged pharmacists in dispensing medications for OUD (MOUD), few studies have evaluated collaborative care models in which pharmacists are an active, integrated part of a primary care team offering OUD care. METHODS This study seeks to implement a pharmacist integrated MOUD clinical model (called PrIMO) and evaluate its feasibility, acceptability, and impact across four diverse primary care sites. The Consolidated Framework for Implementation Research is used as an organizing framework for study development and interpretation of findings. Implementation Facilitation is used to support PrIMO adoption. We assess the primary outcome, the feasibility of implementing PrIMO, using the Stages of Implementation Completion (SIC). We evaluate the acceptability and impact of the PrIMO model at the sites using mixed-methods and combine survey and interview data from providers, pharmacists, pharmacy technicians, administrators, and patients receiving MOUD at the primary care sites with patient electronic health record data. We hypothesize that it is feasible to launch delivery of the PrIMO model (reach SIC Stage 6), and that it is acceptable, will positively impact patient outcomes 1 year post model launch (e.g., increased MOUD treatment retention, medication regimen adherence, service utilization for co-morbid conditions, and decreased substance use), and will increase each site's capacity to care for patients with MOUD (e.g., increased number of patients, number of prescribers, and rate of patients per prescriber). DISCUSSION This study will provide data on a pharmacist-integrated collaborative model of care for the treatment of OUD that may be feasible, acceptable to both site staff and patients and may favorably impact patients' access to MOUD and treatment outcomes. TRIAL REGISTRATION The study was registered on Clinicaltrials.gov (NCT05310786) on April 5, 2022, https://www. CLINICALTRIALS gov/study/NCT05310786?id=NCT05310786&rank=1.
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Affiliation(s)
- Bethany McLeman
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA.
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA.
| | - Phoebe Gauthier
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Laurie S Lester
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | | | - Vernon Gardner
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
| | - Sarah K Moore
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Paul J Joudrey
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lisa Saldana
- Lighthouse Institute, Chestnut Health Systems, Eugene, OR, USA
| | - Gerald Cochran
- University of Utah, Salt Lake City, UT, USA
- Greater Intermountain Node, NIDA Drug Abuse Treatment Clinical Trials Network, Salt Lake City, UT, USA
| | | | | | | | | | | | | | - Tess Gallant
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Jesse S Boggis
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Deepika Rao
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | | | - Nicholas Cox
- University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | | | - Ekow Ambaah
- Harbor Care Health & Wellness, Nashua, NH, USA
| | - Udi Ghitza
- National Institute on Drug Abuse, North Bethesda, MD, USA
| | - David A Fiellin
- New England Consortium Node, NIDA Drug Abuse Treatment Clinical Trials Network, New Haven, CT, USA
- Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lisa A Marsch
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
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Craig DW, Walker TJ, Sharma SV, Cuccaro P, Heredia NI, Pavlovic A, DeFina LF, Kohl HW, Fernandez ME. Examining associations between school-level determinants and the implementation of physical activity opportunities. Transl Behav Med 2024; 14:89-97. [PMID: 37713255 PMCID: PMC10849171 DOI: 10.1093/tbm/ibad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
School-based physical activity (PA) opportunities can help students engage in greater amounts of daily PA, meet PA guidelines, and lead to improved health and educational outcomes. However, we do not completely understand the organizational challenges to implementing these opportunities successfully. This exploratory study examined associations between school-level determinants and the implementation of school-based PA opportunities. We analyzed cross-sectional survey data from schools (n = 46) participating in the Healthy Zone School Program (HZSP) (Dallas, Texas, USA) during 2019-2020. Respondents completed an electronic survey that included measures of school-level determinants (e.g. culture, leadership, priority) and the implementation of school-based PA opportunities. We used linear regression models to examine associations between determinants and implementation outcomes (number of PA opportunities delivered, perceived overall success of each PA program/activity used). After adjusting for campus type (i.e. elementary, middle, high, K-12), student race/ethnicity, and percentage of economically disadvantaged students, no constructs were associated with the number of PA opportunities implemented. Linear regression models suggest access to knowledge and information (β = 0.39, P = .012, 95% CI = 0.24-1.44) and implementation climate (β = 0.34, P = .045, 95% CI = 0.02-1.59) were positively associated with the success of school-based PA opportunities. Our findings provide suggestive evidence that access to knowledge and information and a supportive school climate may improve the overall success of PA opportunities provided to students. Future research should examine additional school-level determinants to understand their importance to implementation and inform the development of strategies to improve schools' capacity for implementing PA opportunities successfully.
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Affiliation(s)
- Derek W Craig
- Department of Health Promotion and Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, 7000 Fannin Street, Houston, TX 77030,USA
| | - Timothy J Walker
- Department of Health Promotion and Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, 7000 Fannin Street, Houston, TX 77030,USA
| | - Shreela V Sharma
- Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas Health Science Center at Houston School of Public Health, 1200 Pressler Street, Houston, TX 77030, USA
| | - Paula Cuccaro
- Department of Health Promotion and Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, 7000 Fannin Street, Houston, TX 77030,USA
| | - Natalia I Heredia
- Department of Health Promotion and Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, 7000 Fannin Street, Houston, TX 77030,USA
| | - Andjelka Pavlovic
- Division of Youth Education, The Cooper Institute, 12330 Preston Road, Dallas, TX 75230, USA
| | - Laura F DeFina
- Division of Youth Education, The Cooper Institute, 12330 Preston Road, Dallas, TX 75230, USA
| | - Harold W Kohl
- Department of Kinesiology and Health Education, The University of Texas at Austin, 2109 San Jacinto Boulevard, Austin, TX 78712, USA
- Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas Health Science Center at Houston School of Public Health, 1616 Guadalupe Street, Austin, TX 78701USA
| | - Maria E Fernandez
- Department of Health Promotion and Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, 7000 Fannin Street, Houston, TX 77030,USA
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Sklar M, Ehrhart MG, Ramirez N, Carandang K, Kuhn N, Day A, Aarons GA, Williams NJ. Implementation leadership and implementation climate in context: A single organization intrinsic case study for implementation of digital measurement-based care. IMPLEMENTATION RESEARCH AND PRACTICE 2024; 5:26334895241236680. [PMID: 38550748 PMCID: PMC10976481 DOI: 10.1177/26334895241236680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Background Although studies have demonstrated that implementation leadership and climate are important constructs in predicting evidence-based practice (EBP) implementation, concrete descriptions of how they operate during organizational implementation efforts are lacking. This case study fills that gap through an in-depth description of an organization with effective implementation leadership that successfully built a strong implementation climate. This case study provides an illustration of implementation leadership and climate in tangible, replicable terms to assist managers, practitioners, and researchers in addressing the organizational context in their own implementation projects. Method A single organization, intrinsic case study was employed to paint a multifaceted picture of how one organization leveraged implementation leadership to strengthen a climate for the successful implementation of digital measurement-based care. The case was drawn from a cluster-randomized trial designed to test the effects of a leadership-focused implementation strategy on youth-level fidelity and clinical outcomes of digital measurement-based care. Following the completion of the trial, case study activities commenced. Descriptive summaries of multiple data sources (including quantitative data on implementation leadership and climate, coaching call and organizational alignment meeting recordings and notes, and development plans) were produced and revised iteratively until consensus was reached. Leadership actions were analyzed for corresponding dimensions of implementation leadership and climate. Results Specific actions organizational leaders took, as well as the timing specific strategies were enacted, to create a climate for implementation are presented, along with lessons learned from this experience. Conclusion This case study offers concrete steps organizational leaders took to create a consistent and aligned message that the implementation of a specific EBP was a top priority in the agency. The general approach taken to create an implementation climate provides several lessons for leaders, especially for EBPs that have broad implications across an organization.
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Affiliation(s)
- Marisa Sklar
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
- UC San Diego ACTRI Dissemination and Implementation Science Center, La Jolla, CA, USA
- Child and Adolescent Services Research Center, San Diego, CA, USA
| | - Mark G. Ehrhart
- Department of Psychology, University of Central Florida, Orlando, FL, USA
| | - Nallely Ramirez
- Institute for the Study of Behavioral Health and Addiction, Boise State University, Boise, ID, USA
| | | | | | - Ana Day
- Oregon Community Programs, Eugene, OR, USA
| | - Gregory A. Aarons
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
- UC San Diego ACTRI Dissemination and Implementation Science Center, La Jolla, CA, USA
- Child and Adolescent Services Research Center, San Diego, CA, USA
| | - Nathaniel J. Williams
- Institute for the Study of Behavioral Health and Addiction, Boise State University, Boise, ID, USA
- School of Social Work, Boise State University, Boise, ID, USA
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Hamm RF, Levine LD, Quigley E, Beidas RS. An evaluation of implementation climate in inpatient maternity care: a cross-sectional survey study. J Matern Fetal Neonatal Med 2023; 36:2185119. [PMID: 36863714 PMCID: PMC10207965 DOI: 10.1080/14767058.2023.2185119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVE Researchers in obstetrics and gynecology are continuously generating new evidence to inform clinical care delivery. Yet, much of this newly emerging evidence fails to be rapidly and effectively integrated into routine clinical practice. Implementation climate refers to clinicians' perceptions of to what degree organizations support and reward use of an evidence-based practice (EBP) and is an important construct in the science of implementation in healthcare. Little is known about implementation climate for EBPs in maternity care. Thus, we aimed to (a) determine the reliability of the Implementation Climate Scale (ICS) for use in inpatient maternity care, (b) describe implementation climate in inpatient maternity care overall, and (c) compare individual perceptions of implementation climate between physician and nursing clinicians on these units. STUDY DESIGN We performed a cross-sectional survey of clinicians in inpatient maternity units across 2 urban, academic hospitals in the northeastern United States in 2020. Clinicians completed the 18-question validated ICS [scored 0-4]. Scale reliability by role was evaluated using Cronbach's α. Subscale and total scores were described overall and compared by physician versus nursing role using independent t-tests, as well as linear regression to control for confounders. RESULTS 111 clinicians completed the survey (physicians = 65; nursing = 46). Physicians were less likely to identify as female (75.4% vs. 100.0%, p < .001), but were of similar age and years of experience as nursing clinicians. Reliability of the ICS was excellent, with Cronbach's α of 0.91 and 0.86 among physicians and nursing clinicians, respectively. Scores were notably low for implementation climate in maternity care overall and for all subscales. ICS total scores were also higher among physicians as compared to nurses (2.18(±0.56) vs. 1.92(±0.50), p = .02), which remained significant in multivariable modeling (p = .02). Unadjusted subscale scores were higher among physicians in Recognition for EBP (2.68(±0.89) vs. 2.30(±0.86), p = .03) and Selection for EBP (2.24(±0.93) vs. 1.62(±1.04), p = .002). After adjustment for potential confounders, subscale scores for Focus on EBP (p = .04) and Selection for EBP (p = .002) were all higher among physicians. CONCLUSIONS This study supports the ICS as a reliable scale for measuring implementation climate in the inpatient maternity care setting. Notably lower implementation climate scores across subscales and roles compared to other settings may underlie the vast evidence to practice gap in obstetrics. In order to successfully implement practices that reduce maternal morbidity, we may need to focus on building educational support and rewarding EBP utilization on labor and delivery units, with an emphasis on nursing clinicians.
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Affiliation(s)
- Rebecca F. Hamm
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa D. Levine
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth Quigley
- Department of Nursing, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rinad S. Beidas
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Lin YJ, Ranusch A, Seagull FJ, Sussman JB, Barnes GD. Dynamic interplay between available resources and implementation climate across phases of implementation: a qualitative study of a VA national population health tool. Implement Sci Commun 2023; 4:74. [PMID: 37386501 DOI: 10.1186/s43058-023-00460-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 06/21/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Available resources within an organization can determine the implementation success of an intervention. However, few studies have investigated how the required resources change over the phases of implementation. Using stakeholder interviews, we examined the changes in and interactions between available resources and implementation climate in the implementation and sustainment phases of a national implementation effort for a population health tool. METHODS We conducted a secondary analysis of the interviews with 20 anticoagulation professionals at 17 clinical sites in the Veterans Health Administration health system about their experiences with a population health dashboard for anticoagulant management. Interview transcripts were coded using constructs from the Consolidated Framework for Implementation Research (CFIR) and according to the phase of implementation (pre-implementation, implementation, and sustainment) as defined by the VA Quality Enhancement Research Initiative (QUERI) Roadmap. We analyzed the factors that may determine successful implementation by examining the co-occurrence patterns between available resources and implementation climate across different implementation phases. To illustrate the variations in these determinants across phases, we aggregated and scored coded statements using a previously published CFIR scoring system (- 2 to + 2). Key relationships between available resources and implementation climate were identified and summarized using thematic analysis. RESULTS The resources necessary to support the successful implementation of an intervention are not static; both the quantity and types of resources shift based on the phases of the intervention. Furthermore, increased resource availability does not guarantee the sustainment of intervention success. Users need different types of support beyond the technical aspects of an intervention, and this support varies over time. Specifically, available resources in the form of technological support and social/emotional support help users establish trust in a new technological-based intervention during the implementation phase. Resources that foster and maintain collaboration between users and other stakeholders help them stay motivated during sustainment. CONCLUSIONS Our findings highlight the dynamic nature of available resources and their impacts on the implementation climate across different phases of implementation. A better understanding of the dynamics of available resources over time from the users' perspectives will allow the adaptation of resources to better meet the needs of the intervention stakeholders.
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Affiliation(s)
- Ying-Jen Lin
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Allison Ranusch
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - F Jacob Seagull
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeremy B Sussman
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, 2800 Plymouth Rd, B14 G214, Ann Arbor, MI, 48109-2800, USA.
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Implementation Science for the Practice-Oriented Nurse Leader. Nurs Adm Q 2023; 47:107-117. [PMID: 36862564 DOI: 10.1097/naq.0000000000000572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Senior nurse leaders are accountable for improving patient outcomes efficiently and cost-effectively. Nurse leaders often find heterogeneous patient outcomes across comparable nursing units in the same enterprise, presenting a challenge for nurse leaders tasked with making system-wide quality improvements. Implementation science (IS) offers a promising new approach to guide nurse leaders in understanding why certain implementation efforts meet with success or failure and the barriers faced in making practice changes. Knowledge of IS builds upon evidenced-based practice and quality improvement knowledge, adding to the armamentarium of tools at nurse leaders' disposal for improving nursing and patient outcomes. In this article, we demystify IS, differentiate it from evidence-based practice and quality improvement, describe IS concepts every nurse leader should be familiar with, and outline nurse leaders' role in building IS in their organizations.
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Szota K, Christiansen H, Aarons GA, Ehrhart MG, Fischer A, Rosner R, Steil R, Barke A. Climate for evidence-based mental health care implementation in Germany: psychometric investigation of the Implementation Climate Scale (ICS). Sci Rep 2023; 13:5311. [PMID: 37002318 PMCID: PMC10066389 DOI: 10.1038/s41598-023-32282-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 03/25/2023] [Indexed: 04/03/2023] Open
Abstract
Organizational implementation climate is an important construct in implementation research to describe to what extent implementation is expected, supported, and rewarded. Efforts in bridging the research-practice gap by implementing evidence-based practice (EBP) can benefit from consideration of implementation climate. The Implementation Climate Scale (ICS) is a psychometrically strong measure assessing employees' perceptions of the implementation climate. The present cross-sectional study aimed at providing a German translation and investigating its psychometric properties. The translation followed standard procedures for adapting psychometric instruments. German psychotherapists (N = 425) recruited online completed the ICS, the Evidence Based Practice Attitudes Scale (EBPAS-36D) and the Intention Scale for Providers (ISP). We conducted standard item and reliability analyses. Factorial validity was assessed by comparing an independent cluster model of Confirmatory Factorial Analysis (ICM-CFA), a Bifactor CFA, a Second-order CFA and an (Bifactor) Exploratory Structural Equation Model (ESEM). Measurement invariance was tested using multiple-group CFA and ESEM, convergent validity with correlation analysis between the ICS and the ISP subjective norms subscale (ISP-D-SN). The mean item difficulty was pi = .47, mean inter-item correlation r = .34, and mean item-total correlation ritc = .55. The total scale (ω = 0.91) and the subscales (ω = .79-.92) showed acceptable to high internal consistencies. The model fit indices were comparable and acceptable (Second-order CFA: RMSEA [90% CI] = .077 [.069; .085], SRMR = .078, CFI = .93). Multiple-group CFA and ESEM indicated scalar measurement invariance across gender and presence of a psychotherapy license. Psychotherapists in training reported higher educational support for EBP than licensed psychotherapists (T = 2.09, p = .037, d = 0.25). The expected high correlation between the ICS and the ISP-D-SN was found (r = .59, p < .001). Results for the German ICS confirm good psychometric properties including validity.
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Affiliation(s)
- Katharina Szota
- Department of Psychology, Philipps-University of Marburg, Gutenbergstr. 18, 35032, Marburg, Germany.
| | - Hanna Christiansen
- Department of Psychology, Philipps-University of Marburg, Gutenbergstr. 18, 35032, Marburg, Germany
| | - Gregory A Aarons
- Department of Psychiatry, University of California, 9500 Gilman Drive (0812), La Jolla, San Diego, CA, 92093-0812, USA
| | - Mark G Ehrhart
- Department of Psychology, University of Central Florida, P.O. Box 161390, Orlando, FL, 32816-1390, USA
| | - Anne Fischer
- Department of Psychology, Goethe University Frankfurt, Varrentrappstr. 40-42, 60486, Frankfurt am Main, Germany
| | - Rita Rosner
- Department of Clinical and Biological Psychology, Catholic University of Eichstätt-Ingolstadt, Levelingstr. 7, 85049, Ingolstadt, Germany
| | - Regina Steil
- Department of Psychology, Goethe University Frankfurt, Varrentrappstr. 40-42, 60486, Frankfurt am Main, Germany
| | - Antonia Barke
- Division of Clinical Psychology and Psychological Intervention, Institute of Psychology, University of Duisburg-Essen, Universitätsstr. 2, S06 S03 B24, 45141, Essen, Germany
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Shuman CJ, Ehrhart MG, Veliz PT, Titler MG. Perceptual differences in nursing implementation leadership and climate: a cross-sectional study. Implement Sci Commun 2023; 4:9. [PMID: 36670493 PMCID: PMC9854059 DOI: 10.1186/s43058-023-00392-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 01/09/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The literature on perceptual differences between managers and staff regarding social dynamic factors (e.g., leadership, climate) in nursing settings is sparse. Addressing this gap in knowledge is critical for informing implementation efforts and improving patient and organizational outcomes. The purpose of this study was to test the perceptual differences regarding implementation leadership and implementation climate between nursing staff and their managers. METHODS This study was a secondary analysis of cross-sectional survey data collected in 2016-2017. The setting included 22 adult medical-surgical units nested in 7 acute care hospitals in the Eastern and Midwestern United States. Participants were registered nurses (N = 261) and nurse managers (N = 22) who completed an electronic survey consisting of the Implementation Leadership Scale (ILS), the Implementation Climate Scale (ICS), and demographic items. Differences in perception were analyzed at the unit level using structural equation modeling to develop latent difference score models (LDS). We assessed associations of the LDSs with manager ILS and ICS scores, years of nursing experience, and years of experience working on the current unit. The association of ILS LDS with the observed nursing staff ICS scores was also analyzed. RESULTS Higher manager scores on the ILS and ICS were associated with greater perceptual differences in implementation leadership and implementation climate. Greater years of experience as a nurse were associated with greater perceptual differences in ILS and ICS scores. Greater tenure on the unit was associated with smaller differences on the ILS knowledge domain. Greater perceptual differences regarding implementation leadership were associated with worse staff ratings of implementation climate. CONCLUSIONS Although this study observed significant relationships among manager ILS and ICS scores, staff-manager perceptual differences, and staff ratings of implementation climate in nursing settings, it is still unclear why perceptual differences in implementation leadership and climate exist and how to address them. Future studies are warranted to test the effect of perceptual differences on implementation and patient outcomes.
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Affiliation(s)
- Clayton J. Shuman
- grid.214458.e0000000086837370School of Nursing, University of Michigan, 400 N. Ingalls, Room 4162, Ann Arbor, MI 48109 USA ,grid.214458.e0000000086837370Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI USA ,grid.214458.e0000000086837370Center for the Study of Drugs, Alcohol, Smoking, and Health, University of Michigan School of Nursing, Ann Arbor, MI USA
| | - Mark G. Ehrhart
- grid.170430.10000 0001 2159 2859Department of Psychology, University of Central Florida, Orlando, FL USA
| | - Philip T. Veliz
- grid.214458.e0000000086837370School of Nursing, University of Michigan, 400 N. Ingalls, Room 4162, Ann Arbor, MI 48109 USA ,grid.214458.e0000000086837370Center for the Study of Drugs, Alcohol, Smoking, and Health, University of Michigan School of Nursing, Ann Arbor, MI USA
| | - Marita G. Titler
- grid.214458.e0000000086837370School of Nursing, University of Michigan, 400 N. Ingalls, Room 4162, Ann Arbor, MI 48109 USA ,grid.214458.e0000000086837370Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI USA
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10
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Hamm RF, Howell E, James A, Faizon R, Bloemer T, Cohen J, Srinivas SK. Implementation and outcomes of a system-wide women’s health ‘team goal’ to reduce maternal morbidity for black women: a prospective quality improvement study. BMJ Open Qual 2022; 11:bmjoq-2022-002061. [PMID: 36384880 PMCID: PMC9670954 DOI: 10.1136/bmjoq-2022-002061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/01/2022] [Indexed: 11/17/2022] Open
Abstract
ObjectiveIn response to the unacceptable racial disparities in US obstetric outcomes, our health system established a formal goal to reduce maternal morbidity for black women. Here, we describe our process for meeting this equity-focused goal in the context of diverse implementation climates at 5 inpatient sites.Study designTo meet the system goal, we established a collaborative of multidisciplinary, site-based teams. The validated 18-question Implementation Climate Scale (ICS) was distributed to site clinicians at baseline. Sites focused on haemorrhage, performing case reviews of black women meeting morbidity criteria. Comparing cases by site, site-specific areas for improvement in haemorrhage risk assessment, prevention and management emerged. Evidence-based practices (EBPs) were then selected, tailored and implemented by site. Monthly system-wide team meetings included (1) metric tracking and (2) site presentations with discussions around barriers/facilitators to EBP implementation. Maternal morbidity rates among black women were compared the year before goal development (1 July 2019–30 June 2020) to the year after (1 July 2020–30 June 2021).ResultsMean ICS scores for inpatient obstetric units differed by site (p=0.005), with climates more supportive of implementation at urban/academic hospitals. In response to case reviews, sites reported implementing 2 to 8 EBPs to meet the goal. Despite different ICS scores, this process was associated with significant reductions in maternal morbidity for black women from pregoal to postgoal development overall and at sites 1, 2 and 3, with non-statistically significant reductions at sites 4 and 5 (overall: −29.4% reduction, p<0.001).ConclusionsA health system goal of reducing maternal morbidity for black women led to a data-driven, collaborative model for implementing site-tailored interventions. If health systems prioritise equity-focused goals, sites can be supported in implementing EBPs that improve care.
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Affiliation(s)
- Rebecca Feldman Hamm
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elizabeth Howell
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Abike James
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Robert Faizon
- Department of Obstetrics & Gynecology, Lancaster General Health, Lancaster, Pennsylvania, USA
| | - Tina Bloemer
- Department of Obstetrics & Gynecology, Penn Medicine Princeton Medical Center, Plainsboro, New Jersey, USA
| | - Jennifer Cohen
- Department of Neonatology, Chester County Hospital, West Chester, Pennsylvania, USA
| | - Sindhu K Srinivas
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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11
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Shuman CJ, Isaman DJ, Morgan ME, Kukora SK, Rubyan M, Veliz PT, Boyd CJ. Validity and Reliability of the Modified Attitudes About Drug Use in Pregnancy Scale. J Obstet Gynecol Neonatal Nurs 2022; 51:324-335. [PMID: 35341716 DOI: 10.1016/j.jogn.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To contemporize the Attitudes About Drug Abuse in Pregnancy questionnaire, keep the length of the modified scale brief to promote use, and test the psychometric properties of the modified scale among perinatal nurses. DESIGN Cross-sectional survey. SETTING Four hospitals in the Midwestern United States. PARTICIPANTS Registered nurses who worked in perinatal units (N = 440). METHODS We collected data from participants using survey methods. Seven experts in perinatal substance use research and clinical care informed scale modifications. We used a split-sample design involving maternal-newborn units (labor, postpartum) and newborn-focused units (NICU, pediatrics). We evaluated construct validity using factor analysis and reliability using Cronbach's alpha. We tested for differences between units using analysis of variance and Tukey's post hoc honest significant difference test of pairwise differences. RESULTS The final modified scale included 13 items that loaded on one factor and showed internal consistency reliability in both samples (α = .88-.91). We found a statistically significant difference in mean score between NICU and pediatric units; however, the absolute difference was small and likely not clinically significant. CONCLUSIONS The Modified Attitudes About Drug Use in Pregnancy scale has initial evidence for validity and reliability, was updated to reflect current terminology in the field, and is a pragmatic tool for use in research.
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12
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Woltz PC, Granger BB, Reynolds SS. Measuring and Evaluating Clinical Context in Implementation Science Research. AACN Adv Crit Care 2022; 33:103-110. [PMID: 35259215 DOI: 10.4037/aacnacc2022664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Patricia C Woltz
- Patricia C. Woltz is Director of Nursing Research, Evidence-Based Practice, and Clinical Nursing Resource Services, WakeMed Health and Hospitals, 3000 New Bern Ave, Ste 1E, Raleigh, NC 27610
| | - Bradi B Granger
- Bradi B. Granger is Professor, Duke University School of Nursing, and Director, Duke Heart Center Nursing Research Program, Durham, North Carolina
| | - Staci S Reynolds
- Staci S. Reynolds is Assistant Professor, Duke University School of Nursing, and Infection Prevention Clinical Nurse Specialist, Duke University Hospital, Durham, North Carolina
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