The impact of implementation climate on community mental health clinicians’ attitudes toward exposure: An evaluation of the effects of training and consultation

Dynamic interplay between available resources and implementation climate across phases of implementation: a qualitative study of a VA national population health tool

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.

Therapist perceptions of experiential training for exposure therapy

BACKGROUND

Despite evidence for its efficacy, exposure therapy for anxiety is rarely used in routine care settings. Efforts to address one major barrier to its use - therapists' negative beliefs about exposure - have included therapist-level implementation strategies, such as training and consultation. Experiential training, in which therapists themselves undergo exposures, has recently demonstrated feasibility, acceptability and preliminary effectiveness for increasing exposure use.

AIMS

This study aimed to assess: (1) therapists' perceptions of experiential training and (2) barriers and facilitators to implementing exposure following training.

METHOD

Therapists who underwent experiential training (n=12) completed qualitative interviews and quantitative questionnaires. Interviews were coded using an integrated approach, combining both inductive and deductive approaches. Mixed methods analyses examined how themes varied by practice setting (community mental health versus private practice) and exposure use.

RESULTS

Results highlight how therapist-level factors, such as clinician self-efficacy, interact with inner- and outer-setting factors. Participants reported positive perceptions of exposure after training; they noted that directly addressing myths about exposure and experiencing exposures themselves improved their attitudes toward exposure. Consistent with prior literature, issues such as insufficient supervisory support, organizational constraints, and client characteristics made it challenging to implement exposures.

DISCUSSION

Results highlight the benefits of experiential training, while also highlighting the need to consider contextual determinants. Differences in responses across practice settings highlight areas for intervention and the importance of tailoring implementation strategies. Barriers that were specific to therapists who did not use exposure (e.g. hesitancy about its appropriateness for most clients) point to directions for future implementation efforts.