A realist review of interventions and strategies to promote evidence-informed healthcare: a focus on change agency

Using a theoretically informed process evaluation alongside a trial to improve oral health for care home residents

BACKGROUND

Poor oral health is common among older adults residing in care homes impacting their diet, quality of life, self-esteem, general health and well-being. The care home setting is complex and many factors may affect the successful implementation of oral care interventions. Exploring these factors and their embedded context is key to understanding how and why interventions may or may not be successfully implemented within their intended setting.

OBJECTIVES

This methodology paper describes the approach to a theoretically informed process evaluation alongside a pragmatic randomised controlled trial, so as to understand contextual factors, how the intervention was implemented and important elements that may influence the pathways to impact.

MATERIALS AND METHODS

SENIOR is a pragmatic randomised controlled trial designed to improve the oral health of care home residents in the United Kingdom. The trial uses a complex intervention to promote and provide oral care for residents, including education and training for staff.

RESULTS

An embedded, theoretically informed process evaluation, drawing on the PAHRIS framework and utilising a qualitative approach, will help to understand the important contextual factors within the care home that influence both the trial processes and the implementation of the intervention.

CONCLUSION

Utilising an implementation framework as the basis for a theoretically informed process evaluation provides an approach that specifically focuses on the contextual factors that may influence and shape the pathways to impact a given complex intervention a priori, while also providing an understanding of how and why an intervention may be effective. This contrasts with the more common post hoc approach that only focuses on implementation after the empirical results have emerged.

Impact of participation as a peer change agent on peer change agents themselves: a quantitative study of a peer-led, social media-based PrEP promotion intervention

Despite the adoption of pre-exposure prophylaxis (PrEP) as a crucial HIV intervention, uptake remains suboptimal among men who have sex with men, a sexual minority group, due to barriers like cost and stigma. Peer change agents (PCAs) disseminate PrEP information within their social networks. This study explores the reciprocal effects of an online community-based participatory intervention on PCAs, focusing on their transformed PrEP uptake perceptions-leadership efficacy, social network dynamics, attitudes, perceived benefits and barriers and self-efficacy. Leveraging insights from the PrEP Chicago Study, our research addresses a key gap in community-based participatory interventions for PrEP uptake: the transformative experiences and perception shifts of PCAs involved in these interventions. We engaged 20 men who have sex with men, aged 18-45, as PCAs in a one-group pretest-posttest design intervention, which disseminated PrEP communications within their preferred online networks. We utilized the PrEP Chicago Study's 45 Likert items, tailored to reveal the PCAs' transformative potential. Data on PrEP uptake perceptions, sociodemographics and social media use were captured and analyzed using the Wilcoxon matched-pairs signed-rank test, a nonparametric method. PCAs demonstrated significant changes in their PrEP uptake perceptions, including leadership capacity, social network dynamics, attitudes toward PrEP, perceived benefits, barriers and self-efficacy. Our intervention highlights the reciprocal transformation PCAs undergo when disseminating PrEP information. This study adds a new dimension to community-based PrEP interventions and underscores the need for continued refinement of peer-led strategies to optimize the transformative potential of PCAs.

A realist synthesis of educational outreach visiting and integrated academic detailing to influence prescribing in ambulatory care: why relationships and dialogue matter

BACKGROUND

Many quality improvement initiatives in healthcare employ educational outreach visits, integrating academic detailing to bridge evidence-practice gaps and accelerate knowledge translation. Replicability of their outcomes in different contexts varies, and what makes some visiting programmes more successful than others is unclear.

OBJECTIVE

We conducted a realist synthesis to develop theories of what makes educational outreach visiting integrating academic detailing work, for whom, under which circumstances and why, focusing on the clinician-visitor interaction when influencing prescribing of medicines in ambulatory care settings.

METHODS

The realist review was performed in accordance with RAMESES standards. An initial programme theory was generated, academic databases and grey literature were screened for documents with detail on contexts, intervention and outcomes. Using realist logic of analysis, data from 43 documents were synthesised in the generation of a refined programme theory, supported by additional theoretical frameworks of learning and communication.

RESULTS

Twenty-seven interdependent context-mechanism-outcome configurations explain how clinicians engage with educational outreach visits integrating academic detailing through programme design, what matters in programme design and the educational visitor-clinician interaction and how influence extends beyond the visit. They suggest that in addition to relevance, credibility and trustworthiness of a visit's contents, communication and clinical skills of educational visitors, the relationship between the educational visitor and clinician, built on a dialogue of learning from and sense-making with each other, creates conditions of critical thinking which are conducive to facilitating prescribing practice change when necessary.

CONCLUSION

This realist synthesis elucidates that the quality of clinician-educational visitor interactions is pivotal to educational outreach visiting programmes. Building and sustaining relationships, and establishing an open dialogue are important; neglecting these undermines the impact of visits. Educational visitors can facilitate clinicians' reflection on practice and influence their prescribing. Clinicians value the discussion of individualised, tailored information and advice they can translate into their practice.

PROSPERO REGISTRATION NUMBER

CRD42021258199.

Change agent's role in facilitating use of technology in residential aged care: A systematic review

OBJECTIVE

To synthesise the evidence on the roles and outcomes of change agents in facilitating the use of powered technology systems and devices for staff end-users in residential aged care workplaces.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

CINAHL, MEDLINE and EMBASE databases were searched for articles published in English between January 2010 and July 2022.

REVIEW METHODS

Two of three reviewers independently screened each title and abstract, and subsequently the full texts of selected records. The Mixed Method Appraisal Tool was used to assess the quality of the included articles.

RESULTS

Of 3,680 records identified, ten articles reporting nine studies were included. In all the studies, the change agent role was a minor component embedded within implementation processes. Three key change agent roles were identified: 1) providing guidance, expertise, and support with implementing a new technology; 2) delivering training to others, and 3) troubleshooting and responding to issues. The key outcome of change agent roles related to achieving project implementation milestones and higher levels of implementation of technology. Change agent processes, however, were compromised when the designated change agent role was included late in the implementation process, or was not supported, recognised, embraced, or when roles or responsibilities were unclear. The direct contribution of change agents was difficult to elucidate because the roles and outcomes of change agents were embedded in multi-faceted implementation strategies.

CONCLUSIONS

The change agent can play an important role in facilitating technology implementation by providing support, training, and troubleshooting. Challenges with the change agent role included unclear role expectations and appointment late in the implementation process. Overall, there was limited evidence specific to the role and outcome of the change agent role to inform ideal approaches for their role in technology facilitation for end-users in residential aged care workplaces.

A realist review of the effective implementation of the ICU Liberation Bundle in the paediatric intensive care unit setting

OBJECTIVE

The objective of this study was to produce an evidence base of what works, for whom, and in what context when implementing the ICU Liberation Bundle into the paediatric intensive care unit (PICU).

REVIEW METHOD USED

This is a realist review (a review that considers what works, for whom, and in what context) of contemporary international literature.

DATA SOURCES

Data were collected via electronic searches of CINAHL, PubMed, EMBASE and MEDLINE, Google Scholar, and Web of Science for articles published before October 2020.

REVIEW METHOD

An initial scoping search identified the underpinning theory of the implementation of the ICU Liberation Bundle (a multifactor intervention aimed at improving patient outcomes) which was mapped onto the Consolidated Framework for Implementation Research (CFIR). We identified 547 unique citations; 12 full-text papers were included that reported eight studies. Data were extracted and mapped to the CFIR domains.

RESULTS

Data mapped to all CFIR domains. Characteristics of individuals included involvement of key stakeholders, champions, and parents and understanding of staff attitudes and perceptions of the intervention, and all bedside staff members were involved and given training. Within the inner setting, understanding of unit culture, ensuring effective support systems in place, knowledge of the baseline, and leadership support, and buy-in were important. Culture of family-centred care and alignment of the intervention to national guidelines related to the outer setting. Intervention characteristics included the number and timings of interventions, de-escalation rounding checklists, the use of age-appropriate and validated assessment tools, and local policies for the bundle. The process included set training program, senior unit/hospital team consultation on all processes, continual audit adherence to the bundle and feedback, and celebration of successes.

CONCLUSIONS

This novel realist review of the literature identified that successful implementation of the ICU Liberation Bundle into PICU settings involves the following: (i) a thorough understanding of the PICU context, including baseline metrics, resources, and staff attitudes; (ii) using contextual information to adapt the intervention elements to ensure fit; and (iii) both clinical effectiveness and implementation outcomes must be measured. Registration of review: PROSPERO 2020 CRD42020211944.

Barriers and Facilitators to Knowledge Brokering Activities: Perspectives from Knowledge Brokers Working in Canadian Rehabilitation Settings

INTRODUCTION

Knowledge translation experts advocate for employing knowledge brokers (KBs) to promote the uptake of research evidence in health care settings. Yet, no previous research has identified potential barriers for KBs to promote the uptake of research evidence in rehabilitation settings. This study aimed to identify the barriers and facilitators for KBs in Canadian rehabilitation settings as perceived by individuals serving as KBs.

METHODS

Qualitative study using semistructured telephone interviews with individuals performing KB activities in rehabilitation settings across Canada. The interview topic guide was informed by the Consolidated Framework for Implementation Research (CFIR) and consisted of 20 questions covering three domains (characteristics of individuals, inner setting, and outer settings). We conducted qualitative descriptive analysis combining deductive coding guided by the CFIR.

RESULTS

Characteristics of individuals included having communication skills, clinical experience, research skills, and interpersonal features, in addition to being confident and motivated and receiving training. The inner setting domain included having constant networking with stakeholders and being aware of stakeholders' needs, in addition to resources availability, leadership engagement, knowledge accessibility, prioritizing brokering activities, and monitoring KBs' performance. Finally, the outer setting domain showed that KBs need to be connected to a community of practice to promote information exchange and avoid work duplications.

DISCUSSION

Factors likely to hinder or promote the optimal use of KBs within Canadian rehabilitation settings include skill sets and networking abilities; organizational culture, resources, and leadership engagement; and the need for specific training for KBs and for evaluation tools to monitor their performance.

Training and support for the role of facilitator in implementation of innovations in health and community care: a scoping review protocol

BACKGROUND

Implementing and sustaining innovations in clinical practice, such as evidence-based practices, programmes, and policies, is frequently described as challenging. Facilitation as a strategy for supporting implementation requires a facilitator, i.e. an individual with a designated role to support the implementation process. A growing number of studies report that facilitation can help tackle the challenges in implementation efforts. To optimise the potential contribution of facilitation as a strategy to improve the implementation of new practices, there is a need to enhance understanding about what training and support is required for individuals in the facilitator role. The objective of this scoping review is to map how facilitators have been trained for, and supported in, the facilitator role in implementation studies in health and community care. Specifically, the review aims to examine what is reported on training and support of facilitators in terms of learning outcomes, content, dose, mode of delivery, learning activities, and qualifications of the trainers and how the facilitators perceive training and support.

METHODS

This scoping review will follow the guidance of the Joanna Briggs Institute and the PRISMA Extension for Scoping Review checklist. We will include articles in which (a) facilitation is deployed as an implementation strategy, with identified facilitator roles targeting staff and managers, to support the implementation of specified innovations in health or community care, and (b) training and/or support of facilitators is reported. We will exclude articles where facilitation is directed to education or training in specific clinical procedures or if facilitation supports the implementation of general quality improvement systems. All types of peer-reviewed studies and study protocols published in English will be included. A systematic search will be performed in MEDLINE (Ovid), Embase (embase.com), Web of Science Core Collection, and CINAHL (Ebsco).

DISCUSSION

The proposed scoping review will provide a systematic mapping of the literature on the training and support of implementation facilitators and contribute useful knowledge within the field of implementation science to inform future facilitation initiatives.

SYSTEMATIC REVIEW REGISTRATION

Registered at Open Science Framework (registration https://doi.org/10.17605/OSF.IO/M6NPQ ).

Mechanisms of change in external implementation support: A conceptual model and case examples to guide research and practice

Background

External implementation support (EIS) is a well-recognized feature of implementation science and practice, often under related terms such as technical assistance and implementation facilitation. Existing models of EIS have gaps related to addressing practice outcomes at both individual and organizational levels, connecting practice activities to intended outcomes, or grounding in well-established theories of behavior and organization change. Moreover, there have been calls to clarify the mechanisms of change through which EIS influences related outcomes.

Method

In this article, we theorize about mechanisms of change within EIS. Our theorizing process aligns with the approach advocated by Kislov et al. We aim to consolidate prior EIS literature, combining related constructs from previous empirical and conceptual work while drawing on our extensive EIS experience to develop a higher-order, midrange theory of change.

Results

Our theory of change is empirically and practically informed, conceptually situated within an established grand theory of change, and guided by eight practice principles and social cognitive theory. The theory of change proposes 10 core practice components as mechanisms of change within EIS. When used according to underlying theory and principles, they are believed to contribute to favorable practice outcomes at individual, team, organizational, and system levels. The model offers flexibility by recognizing the need for sequential support processes and the demand to practice in dynamic and responsive ways. Case examples are presented to illustrate major themes and patterns of the model in action.

Conclusions

The proposed model is intended to support prospective EIS studies by conceptualizing discernable practice components with hypothesized relationships to proximal and distal practice outcomes. The model can be behaviorally operationalized to compliment and extend competency-based approaches to implementation support practitioner (ISP) training and coaching. Over time, the model should be refined based on new empirical findings and contributions from ISPs across the field.

Trajectory of external implementation support activities across two states in the United States: A descriptive study

Background

Reporting on strategies to advance implementation outcomes is imperative. The current study reports descriptive information about external implementation support (EIS) provided over 5 years to 13 regions in North Carolina and South Carolina scaling an evidence-based system of parenting and family supports. Regional support teams operating through the Implementation Capacity for Triple P (ICTP) projects employed core practice components (CPCs) for EIS as proposed by Aldridge et al. and further operationalized by members of The Impact Center at FPG Child Development Institute, UNC-Chapel Hill.

Method

Practice activities associated with CPCs were developed and iteratively refined across the study period. ICTP regional support teams systematically tracked their use of CPCs and related activities following each substantive support interaction. Tracking included the duration of time a CPC was employed and the use of specific practice activities associated with that CPC. Data were aggregated by month of the relationship to account for differential start dates across regions.

Results

From November 2016 through December 2021, ICTP support teams tracked 749 support interactions with Triple P regions in North Carolina and South Carolina. Monthly support decreased year over year, though dose varied considerably. Patterns of CPC use indicated a high dose of "foundational" and "co-design" CPCs early, followed by a blended and more diverse use thereafter, with some notable trends. Practice activities considered essential to influencing intended practice outcomes were characterized by higher rates of use. Like CPCs, practice activities were used dynamically across the study period.

Conclusions

This descriptive study offers a case study for how EIS might be operationalized, tracked, and employed. Findings suggest several interpretations that might refine our understanding and use of EIS. Although the nature of this practical report precludes generalizability of findings, directions for future research and practice are discussed.

Protecting healthcare workers during a pandemic: what can a WHO collaborating centre research partnership contribute?

Objectives

To ascertain whether and how working as a partnership of two World Health Organization collaborating centres (WHOCCs), based respectively in the Global North and Global South, can add insights on "what works to protect healthcare workers (HCWs) during a pandemic, in what contexts, using what mechanism, to achieve what outcome".

Methods

A realist synthesis of seven projects in this research program was carried out to characterize context (C) (including researcher positionality), mechanism (M) (including service relationships) and outcome (O) in each project. An assessment was then conducted of the role of the WHOCC partnership in each study and overall.

Results

The research found that lower-resourced countries with higher economic disparity, including South Africa, incurred greater occupational health risk and had less acceptable measures to protect HCWs at the onset of the COVID-19 pandemic than higher-income more-equal counterpart countries. It showed that rigorously adopting occupational health measures can indeed protect the healthcare workforce; training and preventive initiatives can reduce workplace stress; information systems are valued; and HCWs most at-risk (including care aides in the Canadian setting) can be readily identified to trigger adoption of protective actions. The C-M-O analysis showed that various ways of working through a WHOCC partnership not only enabled knowledge sharing, but allowed for triangulating results and, ultimately, initiatives for worker protection.

Conclusions

The value of an international partnership on a North-South axis especially lies in providing contextualized global evidence regarding protecting HCWs as a pandemic emerges, particularly with bi-directional cross-jurisdiction participation by researchers working with practitioners.

Translating Health Coaching Training into Clinical Practice

Health coaching can benefit people with managing chronic conditions. It considers people's motivations, is person-centred and has the capacity to promote healthy lifestyles and address chronic disease risk factors. However, how health coaching training is translated into routine clinical practice at unit and service levels has been under explored. A metropolitan local health district in Sydney, Australia provided coaching training to health professionals, but the extent to which coaching skills were translated into clinical practice was unknown. A redesign methodology was used to identify barriers and facilitators for training-to-practice translation. Survey and workshop findings indicated that participants were satisfied with the coaching training but found it challenging to apply in clinical practice. Identified opportunities to support the application of health coaching were tailored practical training, post training support, and consensus on the definition of health coaching. Solutions were to develop an internal practical training program, use consistent terminology, and embed organisational support. Adoption of health coaching needs to occur on three levels; individual, workplace and organisation to ensure effective health care delivery. This case study demonstrates the importance of evaluation and diagnostics of contextual barriers and enablers to inform translation into practice.

uSing rolE-substitutioN In care homes to improve ORal health (SENIOR): a study protocol

Background

Dental service provision in the care home sector is poor, with little emphasis on prevention. Emerging evidence suggests that the use of Dental Care Professionals (dental therapists and dental nurses) as an alternative to dentists has the potential to improve preventive advice, the provision of care and access to services within care homes. However, robust empirical evidence from definitive trials on how to successfully implement and sustain these interventions within care homes is currently lacking. The aim of the study is to determine whether Dental Care Professionals could reduce plaque levels of dentate older adults (65 + years) residing in care homes.

Methods

This protocol describes a two-arm cluster-randomised controlled trial that will be undertaken in care homes across Wales, Northern Ireland and England. In the intervention arm, the dental therapists will visit the care homes every 6 months to assess and then treat eligible residents, where necessary. All treatment will be conducted within their Scope of Practice. Dental nurses will visit the care homes every month for the first 3 months and then three-monthly afterwards to promulgate advice to improve the day-to-day prevention offered to residents by carers. The control arm will be ‘treatment as usual’.

Eligible care homes (n = 40) will be randomised based on a 1:1 ratio (20 intervention and 20 control), with an average of seven residents recruited in each home resulting in an estimated sample of 280. Assessments will be undertaken at baseline, 6 months and 12 months and will include a dental examination and quality of life questionnaires. Care home staff will collect weekly information on the residents’ oral health (e.g. episodes of pain and unscheduled care). The primary outcome will be a binary classification of the mean reduction in Silness-Löe Plaque Index at 6 months. A parallel process evaluation will be undertaken to explore the intervention’s acceptability and how it could be embedded in standard practice (described in a separate paper), whilst a cost-effectiveness analysis will examine the potential long-term costs and benefits of the intervention.

Discussion

This trial will provide evidence on how to successfully implement and sustain a Dental Care Professional-led intervention within care homes to promote access and prevention.

Trial registration

ISRCTN16332897. Registered on 3 December 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06487-3.

Evidence-informed practice versus evidence-based practice educational interventions for improving knowledge, attitudes, understanding, and behavior toward the application of evidence into practice: A comprehensive systematic review of UG student

BACKGROUND

To produce graduates with strong knowledge and skills in the application of evidence into healthcare practice, it is imperative that all undergraduate health and social care students are taught, in an efficient manner, the processes involved in applying evidence into practice. The two main concepts that are linked to the application of evidence into practice are "evidence-based practice" and "evidence-informed practice." Globally, evidence-based practice is regarded as the gold standard for the provision of safe and effective healthcare. Despite the extensive awareness of evidence-based practice, healthcare practitioners continue to encounter difficulties in its implementation. This has generated an ongoing international debate as to whether evidence-based practice should be replaced with evidence-informed practice, and which of the two concepts better facilitate the effective and consistent application of evidence into healthcare practice.

OBJECTIVES

The primary objective of this systematic review was to evaluate and synthesize literature on the effectiveness of evidence-informed practice versus evidence-based practice educational interventions for improving knowledge, attitudes, understanding, and behavior of undergraduate health and social care students toward the application of evidence into practice. Specifically, we planned to answer the following research questions: (1) Is there a difference (i.e., difference in content, outcome) between evidence-informed practice and evidence-based practice educational interventions? (2) Does participating in evidence-informed practice educational interventions relative to evidence-based practice educational interventions facilitate the application of evidence into practice (as measured by, e.g., self-reports on effective application of evidence into practice)? (3) Do both evidence-informed practice and evidence-based practice educational interventions targeted at undergraduate health and social care students influence patient outcomes (as measured by, e.g., reduced morbidity and mortality, absence of nosocomial infections)? (4) What factors affect the impact of evidence-informed practice and evidence-based practice educational interventions (as measured by, e.g., course content, mode of delivery, multifaceted interventions, standalone intervention)?

SEARCH METHODS

We utilized a number of search strategies to identify published and unpublished studies: (1) Electronic databases: we searched Academic Search Complete, Academic search premier, AMED, Australian education index, British education index, Campbell systematic reviews, Canada bibliographic database (CBCA Education), CINAHL, Cochrane Library, Database of Abstracts of Reviews on Effectiveness, Dissertation Abstracts International, Education Abstracts, Education complete, Education full text: Wilson, ERIC, Evidence-based program database, JBI database of systematic reviews, Medline, PsycInfo, Pubmed, SciELO (Scientific Electronic Library Online), and Scopus; (2) A web search using search engines such as Google and Google scholar; (3) Grey literature search: we searched OpenGrey (System for Information on Grey Literature in Europe), System for information on Grey Literature, the Society for Research on Educational Effectiveness, and Virginia Henderson Global Nursing e-Repository; (4) Hand searching of journal articles; and (5) Tracking bibliographies of previously retrieved studies. The searches were conducted in June 2019.

SELECTION CRITERIA

We planned to include both quantitative (including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies) and qualitative primary studies (including, case series, individual case reports, and descriptive cross-sectional studies, focus groups, and interviews, ethnography, phenomenology, and grounded theory), that evaluate and compare the effectiveness of any formal evidence-informed practice educational intervention to evidence-based practice educational intervention. The primary outcomes were evidence-informed practice and evidence-based practice knowledge, attitudes, understanding, and behavior. We planned to include, as participants, undergraduate pre-registration health and social care students from any geographical area.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the search results to assess articles for their eligibility for inclusion. The screening involved an initial screening of the title and abstracts, and subsequently, the full-text of selected articles. Discrepancies were resolved through discussion or consultation with a third author. We found no article eligible for inclusion in this review.

MAIN RESULTS

No studies were found which were eligible for inclusion in this review. We evaluated and excluded 46 full-text articles. This is because none of the 46 studies had evaluated and compared the effectiveness of evidence-informed practice educational interventions with evidence-based practice educational interventions. Out of the 46 articles, 45 had evaluated solely, the effectiveness of evidence-based practice educational interventions and 1 article was on evidence-informed practice educational intervention. Hence, these articles were excluded as they did not meet the inclusion criteria.

AUTHORS' CONCLUSIONS

There is an urgent need for primary studies evaluating the relative effectiveness of evidence-informed practice and evidence-based practice educational interventions targeted at improving undergraduate healthcare students' competencies regarding the application of evidence into practice. Such studies should be informed by current literature on the concepts (i.e., evidence-informed practice and evidence-based practice) to identify the differences, similarities, as well as appropriate content of the educational interventions. In this way, the actual effect of each of the concepts could be determined and their effectiveness compared.

Knowledge and attitudes of Implementation Support Practitioners-Findings from a systematic integrative review

BACKGROUND

It requires thoughtful planning and work to successfully apply and sustain research-supported interventions like healthcare treatments, social support, or preventive programs in practice. Implementation support practitioners (ISPs) such as facilitators, technical assistance providers, knowledge brokers, coaches or consultants may be involved to actively support the implementation process. This article presents knowledge and attitudes ISPs bring to their work.

METHODS

Building on a previously developed program logic, a systematic integrative review was conducted. Literature was sourced by searching nine electronic data bases, organizational websites, and by launching a call for publications among selected experts and social media. Article screening was performed independently by two researchers, and data from included studies were extracted by members of the research team and quality-assured by the lead researcher. The quality of included RCTs was assessed based on a framework by Hodder and colleagues. Thematic Analysis was used to capture information on knowledge and attitudes of ISPs across the included studies. Euler diagrams and heatmaps were used to present the results.

RESULTS

Results are based on 79 included studies. ISPs reportedly displayed knowledge about the clinical practice they work with, implementation / improvement practice, the local context, supporting change processes, and facilitating evidence-based practice in general. In particular, knowledge about the intervention to be implemented and its target population, specific improvement / implementation methods and approaches, organizational structures and sensitivities, training, and characteristics of (good) research was described in the literature. Seven themes describing ISPs' attitudes were identified: 1) professional, 2) motivated / motivating / encouraging / empowering, 3) empathetic / respectful / sensitive, 4) collaborative / inclusive, 5) authentic, 6) creative / flexible / innovative / adaptive, and 7) frank / direct / honest. Pertaining to a professional attitude, being responsive and focused were the most prevalent indicators across included publications.

CONCLUSION

The wide range and complexity of knowledge and attitudes found in the literature calls for a comprehensive and systematic approach to collaboratively develop a professional role for ISPs across disciplines. Embedding the ISP role in different health and social welfare settings will enhance implementation capacities considerably.

"I'll leave that to the case managers." Healthcare Service Providers' Perceptions of Organizational Readiness for Change in a Randomized Controlled Trial-A Qualitative Analysis Exploring Implementation Success

Up to 50% of unsuccessful implementations of organizational change are due to a lack of organizational readiness for change (ORC). This qualitative study aims to investigate the experiences of occupational physicians (OPs) and staff of test and training centers (ETTCs) with team effectiveness in the context of ORC. The change setting is the implementation of a new occupational health program in a multicentric randomized controlled trial for musculoskeletal disorders (MSD) in Germany. Two rounds of expert interviews with OPs (1st round: n = 10, 2nd round: n = 13) and one round of expert interviews with ETTCs (n = 9) were conducted and analyzed with a deductive-inductive procedure. The focus of the analysis was the assessment of change commitment and change efficacy, as well as their influence on general ORC on a collective level according to Weiner's model (2009). Differential critical assessment of change by the care providers led to a missing collective change commitment and consequently to a missing organizational change commitment. Main inhibiting factors include lacking feedback about (e.g., recruitment) success, limited time resources of and narrow communication between responsible study staff, along with a low rate of utilization and limited adherence of the study population. Main facilitators include standardized procedures and documentation along with easy-access digital tools. Researchers may use the findings to improve the development of new intervention studies, especially in a randomized setting.

Strategies to promote evidence use for health programme improvement: learning from the experiences of embedded implementation research teams in Latin America and the Caribbean

Background

To achieve global health targets, innovative approaches are needed to strengthen the implementation of efficacious interventions. New approaches in implementation research that bring together health system decision-makers alongside researchers to collaboratively design, produce and apply research evidence are gaining traction. Embedded implementation research (EIR) approaches led by decision-maker principal investigators (DM PIs) appear promising in this regard. Our aim is to describe the strategies study teams employ in the post-research phase of EIR to promote evidence-informed programme or policy improvement.

Methods

We conducted a prospective, comparative case study of an EIR initiative in Bolivia, Colombia and Dominican Republic. Guided by a conceptual framework on EIR, we used semi-structured key informant interviews (n = 51) and document reviews (n = 20) to examine three decision-maker-led study teams (“cases”). Focusing on three processes (communication/dissemination, stakeholder engagement with evidence, integrating evidence in decision-making) and the main outcome (enacting improvements), we used thematic analysis to identify associated strategies and enabling or hindering factors.

Results

Across cases, we observed diverse strategies, shaped substantially by whether the DM PI was positioned to lead the response to study findings within their sphere of work. We found two primary change pathways: (1) DM PIs implement remedial measures directly, and (2) DM PIs seek to influence other stakeholders to respond to study findings. Throughout the post-research phase, EIR teams adapted research use strategies based on the evolving context.

Conclusions

EIR led by well-positioned DM PIs can facilitate impactful research translation efforts. We draw lessons around the importance of (1) understanding DM PI positionality, (2) ongoing assessment of the evolving context and stakeholders and (3) iterative adaptation to dynamic, uncertain circumstances. Findings may guide EIR practitioners in planning and conducting fit-for-purpose and context-sensitive strategies to advance the use of evidence for programme improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00834-1.

Profiling knowledge brokers in the rehabilitation sector across Canada: A descriptive study

RATIONALE

Knowledge brokers (KBs) can help promote the uptake of the latest research evidence into clinical practice. Little is known about who they are, the types of roles they perform, and the training they receive. Establishing a portrait of Canadian KBs working in the rehabilitation sector may inform health care organizations and knowledge translation specialists on how best to advance KBs practices. The overall goal was to describe the profile of KBs working to promote the uptake of evidence within rehabilitation settings in Canada. Specifically, this study aimed to describe the sociodemographic and professional characteristics, work activities, and training of KBs.

METHODS

A cross-sectional online survey was administered to KBs working in rehabilitation settings across Canada. The survey included 20 questions covering sociodemographic and professional characteristics, work activities, and training opportunities. Response frequency and percentage were calculated for all categorical variables, and the weighted average (WA) for each role was calculated across participants. Descriptive analysis was conducted for all open-ended questions.

RESULTS

Of 475 participants accessing the website, 198 completed the survey questionnaire, including 99 clinicians, 35 researchers, and 26 managers. While over two-thirds of respondents had completed a graduate degree, only 38% reported receiving KBs-related training. The respondents' primary roles corresponded to a linking agent (WA = 1.84), followed by capacity builder (WA = 1.76), information manager (WA = 1.71), facilitator (WA = 1.41), and evaluator (WA = 1.32).

CONCLUSIONS

KBs are mostly expert clinicians who tend to perform brokering activities part-time targeting their peers. Participants mostly perform the linking agent, capacity builder, and information roles. Moreover, only a few participants received formal training to perform brokering activities.

Nationwide Environmental Scan of Knowledge Brokers Training

INTRODUCTION

Knowledge brokers (KBs) can promote the uptake of best practice guidelines in rehabilitation. Although many institutions offer training opportunities to health care professionals who wish to undertake KBs roles, the characteristics and content of those educational training opportunities (ETOs) are currently unknown. This study aimed to describe the ETOs available to rehabilitation professionals in Canada and determine whether the ETOs meet the competencies expected of the KBs roles.

METHODS

We conducted a Canada-wide environmental scan to identify ETOs using three strategies: online search, phone calls, and snowball. To be included in the study, ETOs had to be offered to rehabilitation professionals in Canada and be targeting KBs competencies and/or roles. We mapped each of the content to the KBs competencies (knowledge and skills) within the five roles of KBs: information manager, linking agent, capacity builder, facilitator, and evaluator.

RESULTS

A total of 51 ETOs offered in three Canadian provinces, British Columbia, Ontario, and Quebec, were included in the analysis. For KBs competencies, 76% of ETOs equipped attendees with research skills, 55% with knowledge brokering skills, and 53% with knowledge on implementation science. For KBs roles, over 60% of ETOs supported attendees to in performing the capacity builder role and 39% the evaluator role.

DISCUSSION

Findings suggest that ETOs focused primarily on preparing participants with the research and knowledge brokering skills required to perform the capacity builder and evaluator roles. Comprehensive educational training covering all KBs roles and competencies are needed.

Exploring Occupational Therapists' Experiences in U.S. Primary Care Settings: A Qualitative Study

IMPORTANCE

Occupational therapy's scope of practice aligns with the goals of comprehensive primary care set forth by the 2010 Patient Protection and Affordable Care Act (Pub. L. 111-148). To successfully integrate occupational therapy into primary care, we must understand occupational therapy practitioners' experiences in this setting.

OBJECTIVE

To explore facilitators of, barriers to, and recommendations for integrating occupational therapy into primary care.

DESIGN

A descriptive qualitative design that incorporated semistructured interviews, member checking sessions, and deductive thematic analysis. Interviews were structured to capture occupational therapists' experiences of and recommendations for practicing in primary care.

SETTING

Primary care.

PARTICIPANTS

A purposive sample of licensed occupational therapists with at least 6 mo primary care experience in the United States.

RESULTS

Seven participants reported 1 to 8 yr of experience in primary care. Four themes emerged that contextualized the experiences of occupational therapists in primary care. The first theme captured the process of gaining entry onto the primary care team. Once structurally embedded on the team, the second and third themes, respectively, captured barriers and facilitators to navigating team-based care and providing patient-centered care. The fourth theme reflected participants' vision and ideas of how to expand reach nationally to promote consistent integration of occupational therapy into primary care. Conclusion and Relevance: Given the important role of an interprofessional primary care team in improving population health, this study is timely in that it explored occupational therapists' experiences in this emerging practice area. What This Article Adds: Occupational therapists in this study used their skills, resources, and networks to become part of a primary care team. They indicated that they contributed to positive outcomes through working with patients on self-management, functional problem solving, and behavior change.

Toward Nurses' Transformative Agency in Transitional Care for Older Adults: A Change-Laboratory Intervention

Mobilization of nurses' agency across healthcare sectors is needed to counter challenges associated with older adults' transitions between hospital and primary care. Based on Cultural Historical Activity theory and the Change Laboratory method, we developed a learning intervention with 16 nurses. The aim was to foster the nurses' transformative agency to improve care. Video-recording of nine learning sessions were transcribed and analyzed. Results demonstrated that shared transformative agency exhibited as an emergent phenomenon crossing sectoral boundaries as a prerequisite for change in transitional care. The nurses progressed from acting as individuals criticizing the current conditions to collectively forming a vision around a transitional care model. This was nurtured through the nurses' negotiations which included a recognition of sharing similar challenges deriving from the healthcare organization and related financial restrictions, and conflicting healthcare and nursing ideals across healthcare sectors. The evolution of transformative agency was grounded in a professional nursing identity.

Embedding mentoring to support trial processes and implementation fidelity in a randomised controlled trial of vocational rehabilitation for stroke survivors

BACKGROUND

Little guidance exists regarding how best to upskill and support those delivering complex healthcare interventions to ensure robust trial outcomes and implementation fidelity. Mentoring was provided to occupational therapists (OTs) delivering a complex vocational rehabilitation (VR) intervention to stroke survivors. This study aimed to explore mentors' roles in supporting OTs with intervention delivery and fidelity, and to describe factors affecting the mentoring process and intervention delivery.

METHODS

Quantitative data (duration, mode and total time of mentoring support) was extracted from mentoring records and emails between mentors and OTs, alongside qualitative data on barriers and facilitators to intervention delivery. Semi-structured interviews with mentors (n = 6) and OTs (n = 19) explored experiences and perceptions of intervention training, delivery and the mentoring process. Mean total and monthly time spent mentoring were calculated per trial site. Qualitative data were analysed thematically.

RESULTS

Forty-one OTs across 16 sites were mentored between March 2018 and April 2020. Most mentoring was provided by phone or Microsoft Teams (range: 88.6-100%), with the remainder via email and SMS (Short Message Service) text messages. Mentors suggested strategies to enhance trial recruitment, improved OTs' understanding of- and adherence to trial processes, intervention delivery and fidelity, and facilitated independent problem-solving. Barriers to mentoring included OT non-attendance at mentoring sessions and mentors struggling to balance mentoring with clinical roles. Facilitators included support from the trial team and mentors having protected time for mentoring.

CONCLUSIONS

Mentoring supported mentee OTs in various ways, but it remains unclear to what extent the OTS would have been able to deliver the intervention without mentoring support, or how this might have impacted fidelity. Successful implementation of mentoring alongside new complex interventions may increase the likelihood of intervention effectiveness being observed and sustained in real-life contexts. Further research is needed to investigate how mentors could be selected, upskilled, funded and mentoring provided to maximise impact. The clinical- and cost-effectiveness of mentoring as an implementation strategy and its impact on fidelity also requires testing in a future trial.

TRIAL REGISTRATION

ISRCTN, ISRCTN12464275 . Registered on 13th March 2018.

Determinants that influence knowledge brokers' and opinion leaders' role to close knowledge practice gaps in rehabilitation: A realist review

RATIONALE

Despite the available evidence to support optimal practices in rehabilitation, significant knowledge practice gaps persist. Opinion leaders (OLs) and knowledge brokers (KBs) can enhance the success of knowledge translation (KT) interventions and improve uptake of best practices among clinicians. However, the literature on the mechanisms underpinning OLs'/KBs' activities, and guidance on the type of support needed for successful implementation of these roles in rehabilitation contexts is scarce. This research aimed to highlight the differences and similarities between OLs and KBs with respect to context, mechanism, and outcomes as well as describe the common patterns of OLs and KBs by creating a context-mechanism-outcomes configuration.

METHODS

We conducted a realist review to synthesize the available evidence on OLs/KBs as active KT strategies. A search was conducted across five databases up to November 2019. Two independent reviewers extracted the data using a structured form. A context-mechanism-outcome configuration was used to conceptualize a cumulative portrait of the features of OLs/KBs roles.

RESULTS

The search identified 3282 titles after removing duplicates. Seventeen studies (reported in 20 articles) were included in the review. Findings suggest a number of desirable features of OLs/KBs roles that may maximize the achievement of targeted outcomes namely being (a) embedded within their organization as "insiders"; (b) adequately skilled to perform their role; (c) identified as able to fulfil the role; (d) appropriately trained; and (e) able to use different KT interventions.

CONCLUSION

Findings of this realist review converge to create a context-mechanism-outcomes configuration with suggestions to optimally utilize OLs/KBs in rehabilitation. The configurations suggest desirable features that can lead to a greater potential to achieve targeted goals. It is preferable that OLs/KBs be embedded in the organization and that they are adequately skilful and well-trained. Also, OLs/KBs should perform the required roles using KT interventions adapted to the local context.

Facilitating Guideline Implementation in Primary Health Care Practices

Introduction: Many patients continue to receive suboptimal services, inappropriate, unsafe, and costly care. Underutilization of research by health professionals is a common problem in the primary care setting. Although many theoretical frameworks can be used to help address such evidence-practice gaps, health care professionals may not be aware of the benefits of frameworks or of the most appropriate ones for their context and thus, may be faced with the challenge of selecting and using the most relevant one. Aim: The aim of this article was to describe the process used to adapt a knowledge translation framework to meet the local needs of health professionals working in one large primary care setting. Methods: The authors developed a 5-step approach for guideline implementation. This approach was informed by prior research and the authors’ experiences in supporting multidisciplinary teams of health care professionals during the implementation of evidence-based clinical guidelines into primary care practices. To ensure that the 5-step approach was practical and suitable for the context of guideline implementation by multidisciplinary teams in primary health care, the implementation team adapted the “knowledge-to-action” framework using a multistep process. Results: The implementation approach consisted of the following 5 steps: identification, context analysis, development of implementation plan, evaluation, and sustainability. All 5 steps were described alongside details about a national low back pain project. Discussion: This article describes a collaborative, grassroots process that addressed an identified need in one complex context by adapting a knowledge translation framework to meet the local needs of health professionals working in primary care settings. Existing implementation frameworks may be too complex or abstract for use in busy clinical contexts. The 5-step approach presented in this paper resulted in practical steps that are more readily understood by health care professionals and staff on “the ground.”

Applying systems thinking to knowledge mobilisation in public health

CONTEXT

Knowledge mobilisation (KM) is a vital strategy in efforts to improve public health policy and practice. Linear models describing knowledge transfer and translation have moved towards multi-directional and complexity-attuned approaches where knowledge is produced and becomes meaningful through social processes. There are calls for systems approaches to KM but little guidance on how this can be operationalised. This paper describes the contribution that systems thinking can make to KM and provides guidance about how to put it into action.

METHODS

We apply a model of systems thinking (which focuses on leveraging change in complex systems) to eight KM practices empirically identified by others. We describe how these models interact and draw out some key learnings for applying systems thinking practically to KM in public health policy and practice. Examples of empirical studies, tools and targeted strategies are provided.

FINDINGS

Systems thinking can enhance and fundamentally transform KM. It upholds a pluralistic view of knowledge as informed by multiple parts of the system and reconstituted through use. Mobilisation is conceived as a situated, non-prescriptive and potentially destabilising practice, no longer conceptualised as a discrete piece of work within wider efforts to strengthen public health but as integral to and in continual dialogue with those efforts. A systems approach to KM relies on contextual understanding, collaborative practices, addressing power imbalances and adaptive learning that responds to changing interactions between mobilisation activities and context.

CONCLUSION

Systems thinking offers valuable perspectives, tools and strategies to better understand complex problems in their settings and for strengthening KM practice. We make four suggestions for further developing empirical evidence and debate about how systems thinking can enhance our capacity to mobilise knowledge for solving complex problems - (1) be specific about what is meant by 'systems thinking', (2) describe counterfactual KM scenarios so the added value of systems thinking is clearer, (3) widen conceptualisations of impact when evaluating KM, and (4) use methods that can track how and where knowledge is mobilised in complex systems.

What factors influence organisational readiness for change? Implementation of the Australian clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP)

AIMS

Translation of evidence-based psycho-oncology interventions into routine care can significantly improve patient outcomes, yet effective implementation remains challenging due to numerous real-world barriers. A key factor that may influence implementation is organisational readiness for change. This mixed method study sought to identify factors associated with organisational readiness for implementing the Australian clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP).

METHODS

We collected data from multidisciplinary staff across six Australian cancer services who were preparing to implement the ADAPT CP. Services were categorised as having 'high' versus 'mid-range' organisational readiness based on a median split on the Organizational Readiness for Implementing Change (ORIC) questionnaire (score range = 12-60). Qualitative data from the semi-structured interviews based on the Promoting Action Research in Health Services (PARiHS) framework were analysed thematically and compared for services with high- versus mid-range organisational readiness.

RESULTS

Three services with high- (mean ORIC range, 52.25-56.88), and three with mid-range (range, 38.75-46.39) organisational readiness scores were identified. Staff at services reporting higher readiness described a more collaborative and proactive service culture, strong communication processes and greater role flexibility. They also reported greater confidence in overcoming anticipated barriers and clearer strategies for addressing issues.

CONCLUSIONS

Levels of organisational readiness were related to distinct qualitative themes. Targeting these issues in services where readiness is mid-range or low prior to full-scale roll-out may improve staff levels of confidence and efficacy in implementing psycho-oncology-focused interventions.

Context and the evidence-based paradigm: The potential for participatory research and systems thinking in oral health

The implementation of research evidence to promote oral health is critical, given the intransigent and emerging challenges for policymakers at a population level. Despite this, little attention has been paid to implementation research within the evidence-based paradigm. This is important as getting research evidence into clinical practice is not a linear path that consists of simple sequential steps. In this article, we argue that we need to consider a broader range of conceptual and methodological approaches to increase the value of information generated. This should be undertaken either in parallel with empirical and experimental designs, or in some cases, instead of. This is important if we are going to understand the complexity and contextual knowledge of the 'system', within which interventions are implemented. Involving key stakeholders alongside empirical and experimental designs is one helpful approach. Examples of these approaches include Patient and Public Involvement and the development of Core Outcome Sets, where the views of those that will be potentially affected by the research, are included. The use of theoretical frameworks and process evaluations alongside trials are also important, if they are fully integrated into the approach taken to address the research question. A more radical approach is using participatory designs and 'systems thinking'. Participatory approaches include subject matter 'experts by experience'. These include patients, their families, carers, healthcare professionals, services managers, policymakers, commissioners and researchers. Participatory approaches raise important questions about who facilitates the process, when it should happen and how the diverse actors become meaningfully engaged so that their involvement is active, democratic and ongoing. We argue that the issues of control, power and language are central to this and represent a paradigmatic shift to conventional approaches. Systems thinking captures the idea that public health problems commonly involve multiple interdependent and interconnected factors, which interact with each other dynamically. This approach challenges the simplicity of the hierarchy of evidence and linear sequential logic, when it does not account for context. In contrast, systems thinking accepts complexity de novo and emphasizes the need to understand the whole system rather than its individual component parts. We conclude with the idea that participatory and systems thinking help to unpack the diverse agents that are often involved in the generation and translation of evidence into clinical dental practice. It moves our conception of research away from a simple exchange between 'knowledge producers' and 'knowledge users' and raises both methodological and epistemological challenges.

Implementation support practitioners - a proposal for consolidating a diverse evidence base

Background

Workforce development for implementation practice has been identified as a grand challenge in health services. This is due to the embryonic nature of the existing research in this area, few available training programs and a general shortage of frontline service staff trained and prepared for practicing implementation in the field. The interest in the role of “implementation support” as a way to effectively build the implementation capacities of the human service sector has therefore increased. However, while frequently used, little is known about the skills and competencies required to effectively provide such support.

Main body

To progress the debate and the research agenda on implementation support competencies, we propose the role of the “implementation support practitioner” as a concept unifying the multiple streams of research focused on e.g. consultation, facilitation, or knowledge brokering. Implementation support practitioners are professionals supporting others in implementing evidence-informed practices, policies and programs, and in sustaining and scaling evidence for population impact. They are not involved in direct service delivery or management and work closely with the leadership and staff needed to effectively deliver direct clinical, therapeutic or educational services to individuals, families and communities. They may be specialists or generalists and be located within and/or outside the delivery system they serve. To effectively support the implementation practice of others, implementation support practitioners require an ability to activate implementation-relevant knowledge, skills and attitudes, and to operationalize and apply these in the context of their support activities. In doing so, they aim to trigger both relational and behavioral outcomes. This thinking is reflected in an overarching logic outlined in this article.

Conclusion

The development of implementation support practitioners as a profession necessitates improved conceptual thinking about their role and work and how they enable the uptake and integration of evidence in real world settings. This article introduces a preliminary logic conceptualizing the role of implementation support practitioners informing research in progress aimed at increasing our knowledge about implementation support and the competencies needed to provide this support.

The influence of contextual factors on healthcare quality improvement initiatives: a realist review

BACKGROUND

Recognising the influence of context and the context-sensitive nature of quality improvement (QI) interventions is crucial to implementing effective improvements and successfully replicating them in new settings, yet context is still poorly understood. To address this challenge, it is necessary to capture generalisable knowledge, first to understand which aspects of context are most important to QI and why, and secondly, to explore how these factors can be managed to support healthcare improvement, in terms of implementing successful improvement initiatives, achieving sustainability and scaling interventions. The research question was how and why does context influence quality improvement initiatives in healthcare?

METHODS

A realist review explored the contextual conditions that influence healthcare improvement. Realist methodology integrates theoretical understanding and stakeholder input with empirical research findings. The review aimed to identify and understand the role of context during the improvement cycle, i.e. planning, implementation, sustainability and transferability; and distil new knowledge to inform the design and development of context-sensitive QI initiatives. We developed a preliminary theory of the influence of context to arrive at a conceptual and theoretical framework.

RESULTS

Thirty-five studies were included in the review, demonstrating the interaction of key contextual factors across healthcare system levels during the improvement cycle. An evidence-based explanatory theoretical model is proposed to illustrate the interaction between contextual factors, system levels (macro, meso, micro) and the stages of the improvement journey. Findings indicate that the consideration of these contextual factors would enhance the design and delivery of improvement initiatives, across a range of improvement settings.

CONCLUSIONS

This is the first realist review of context in QI and contributes to a deeper understanding of how context influences quality improvement initiatives. The distillation of key contextual factors offers the potential to inform the design and development of context-sensitive interventions to enhance improvement initiatives and address the challenge of spread and sustainability. Future research should explore the application of our conceptual model to enhance improvement-planning processes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017062135.

Gamechanger: harnessing football for social change

Purpose

The purpose of this paper is to present a case study of an intersectoral partnership that has taken place in Scotland (United Kingdom) entitled Gamechanger. The main idea of Gamechanger was for statutory, commercial and voluntary organisations to work in partnership to harness the power of football (soccer), to tackle health inequalities and social exclusion. The paper will detail how Gamechanger has been developed, with reference to the newly developed “Incite” model for effective intersectoral partnership working.

Design/methodology/approach

This paper draws on the authors’ experiences of leading and evaluating intersectoral partnerships from 2015 to 2019. The report draws on the work which took place during that period, and the achievements in relation to Gamechanger.

Findings

Gamechanger has led to significant innovations. It has encouraged sectors to work together, and develop new ways of responding to difficult societal problems.

Originality/value

Gamechanger is believed to be the first initiative of its kind developed with a football club in Scotland.

Conclusions

This work has been developed through robust community-informed efforts. The scope and scale of the projects to deliver community benefits is significant. Gamechanger has provided a means for football to take a different approach to how it works to benefit communities.

Context, complexity and process in the implementation of evidence-based innovation: a realist informed review

Background

This review of scholarly work in health care knowledge translation advances understanding of implementation components that support the complete and timely integration of new knowledge. We adopt a realist approach to investigate what is known from the current literature about the impact of, and the potential relationships between, context, complexity and implementation process.

Methods

Informed by two distinct pathways, knowledge utilization and knowledge translation, we utilize Rogers’ Diffusion of Innovations theory (DOI) and Harvey and Kitson’s integrated- Promoting Action on Research Implementation in Health Service framework (PARIHS) to ground this review. Articles from 5 databases; Medline, Scopus, PsycInfo, Web of Science, and Google Scholar and a search of authors were retrieved. Themes and patterns related to these implementation components were extracted. Literature was selected for inclusion by consensus. Data extraction was iterative and was moderated by the authors.

Results

A total of 67 articles were included in the review. Context was a central component to implementation. It was not clear how and to what extent context impacted implementation. Complexity was found to be a characteristic of context, implementation process, innovations and a product of the relationship between these three elements. Social processes in particular were reported as influential however; descriptions of how these social process impact were limited. Multiple theoretical and operational models were found to ground implementation processes. We offer an emerging conceptual model to illustrate the key discoveries.

Conclusions

The review findings indicate there are dynamic relationship between context, complexity and implementation process for enhancing uptake of evidence-based knowledge in hospital settings. These are represented in a conceptual model. Limited empiric evidence was found to explain the nature of the relationships.

A scoping review of the uses and institutionalisation of knowledge for health policy in low- and middle-income countries

There is growing interest in how different forms of knowledge can strengthen policy-making in low- and middle-income country (LMIC) health systems. Additionally, health policy and systems researchers are increasingly aware of the need to design effective institutions for supporting knowledge utilisation in LMICs. To address these interwoven agendas, this scoping review uses the Arskey and O’Malley framework to review the literature on knowledge utilisation in LMIC health systems, using eight public health and social science databases. Articles that described the process for how knowledge was used in policy-making, specified the type of knowledge used, identified actors involved (individual, organisation or professional), and were set in specific LMICs were included. A total of 53 articles, from 1999 to 2016 and representing 56 countries, were identified. The majority of articles in this review presented knowledge utilisation as utilisation of research findings, and to a lesser extent routine health system data, survey data and technical advice. Most of the articles centered on domestic public sector employees and their interactions with civil society representatives, international stakeholders or academics in utilising epistemic knowledge for policy-making in LMICs. Furthermore, nearly all of the articles identified normative dimensions of institutionalisation. While there is some evidence of how different uses and institutionalisation of knowledge can strengthen health systems, the evidence on how these processes can ultimately improve health outcomes remains unclear. Further research on the ways in which knowledge can be effectively utilised and institutionalised is needed to advance the collective understanding of health systems strengthening and enhance evidence-informed policy formulation.

Feasibility and usefulness of a leadership intervention to implement evidence-based falls prevention practices in residential care in Canada

Background

Leadership is critical to supporting and facilitating the implementation of evidence-based practices in health care. Yet, little is known about how to develop leadership capacity for this purpose. The aims of this study were to explore the (1) feasibility of delivering a leadership intervention to promote implementation, (2) usefulness of the leadership intervention, and (3) participants’ engagement in leadership to implement evidence-based fall prevention practices in Canadian residential care.

Methods

We conducted a mixed-method before-and-after feasibility study on two units in a Canadian residential care facility. The leadership intervention was based on the Ottawa model of implementation leadership (O-MILe) and consisted of two workshops and two individualized coaching sessions over 3 months to develop leadership capacity for implementing evidence-based fall prevention practices. Participants (n = 10) included both formal (e.g., managers) and informal (e.g., nurses and care aids leaders). Outcome measures were parameters of feasibility (e.g., number of eligible candidates who attended the workshops and coaching sessions) and usefulness of the leadership intervention (e.g., ratings, suggested modifications). We conducted semi-structured interviews guided by the Implementation Leadership Scale (ILS), a validated measure of 12-item in four subcategories (proactive, supportive, knowledgeable, and perseverant), to explore the leadership behaviors that participants used to implement fall prevention practices. We repeated the ILS in a focus group meeting to understand the collective leadership behaviors used by the intervention team. Barriers and facilitators to leading implementation were also explored.

Results

Delivery of the leadership intervention was feasible. All participants (n = 10) attended the workshops and eight participated in at least one coaching session. Workshops and coaching were rated useful (≥ 3 on a 0–4 Likert scale where 4 = highly useful) by 71% and 86% of participants, respectively. Participants rated the O-MILe subcategories of supportive and perseverant leadership highest for individual leadership, whereas supportive and knowledgeable leadership were rated highest for team leadership.

Conclusions

The leadership intervention was feasible to deliver, deemed useful by participants, and fostered engagement in implementation leadership activities. Study findings highlight the complexity of developing implementation leadership and modifications required to optimize impact. Future trials are now required to test the effectiveness of the leadership intervention on developing leadership for implementing evidence-based practices.

A description of a tailored knowledge translation intervention delivered by knowledge brokers within public health departments in Canada

Background

While there is an expectation to demonstrate evidence-informed public health there is an ongoing need for capacity development. The purpose of this paper is to provide a description of a tailored knowledge translation intervention implemented by knowledge brokers (KBs), and reflections on the factors that facilitated or hindered its implementation.

Methods

The 22-month knowledge translation intervention, implemented by two KBs, sought to facilitate evidence-informed public health decision-making. Data on outcomes were collected using a knowledge, skills and behavioural assessment survey. In addition, the KBs maintained reflective journals noting which activities appeared successful or not, as well as factors related to the individual or the organisation that facilitated or hindered evidence-informed decision-making.

Results

Tailoring of the knowledge translation intervention to address the needs, preferences and structure of each organisation resulted in three unique interventions being implemented. A consistent finding across organisations was that each site needed to determine where evidence-informed decision-making ‘fit’ within pre-existing organisational processes. Components of the intervention consistent across the three organisations included one-to-one mentoring of teams through rapid evidence reviews, large group workshops and regular meetings with senior management. Components that varied included the frequency of the KB being physically onsite, the amount of time staff spent with the KB and proportion of time spent one-to-one with a KB versus in workshops. Key facilitating factors for implementation included strong leadership, influential power of champions, supportive infrastructure, committed resources and staff enthusiasm.

Conclusions

The results of this study illustrate the importance of working collaboratively with organisations to tailor knowledge translation interventions to best meet unique needs, preferences, organisational structures and contexts. Organisational factors such as leadership, champions and supportive infrastructure play a key role in determining the impact of the knowledge translation interventions. Future studies should explore how these factors can be fostered and/or developed within organisations. While KBs implemented the knowledge translation intervention in this study, more research is needed to understand the impact of all change agent roles including KBs, as well as how these roles can be maintained in the long-term if proven effective.

Comparing theory and non-theory based implementation approaches to improving referral practices in cancer genetics: a cluster randomised trial protocol

Background

Lynch syndrome (LS) is an inherited, cancer predisposition syndrome associated with an increased risk of colorectal, endometrial and other cancer types. Identifying individuals with LS allows access to cancer risk management strategies proven to reduce cancer incidence and improve survival. However, LS is underdiagnosed and genetic referral rates are poor. Improving LS referral is complex, and requires multisystem behaviour change. Although barriers have been identified, evidence-based strategies to facilitate behaviour change are lacking. The aim of this study is to compare the effectiveness of a theory-based implementation approach against a non-theory based approach for improving detection of LS amongst Australian patients with colorectal cancer (CRC).

Methods

A two-arm parallel cluster randomised trial design will be used to compare two identical, structured implementation approaches, distinguished only by the use of theory to identify barriers and design targeted intervention strategies, to improve LS referral practices in eight large Australian hospital networks. Each hospital network will be randomly allocated to a trial arm, with stratification by state. A trained healthcare professional will lead the following phases at each site: (1) undertake baseline clinical practice audits, (2) form multidisciplinary Implementation Teams, (3) identify target behaviours for practice change, (4) identify barriers to change, (5) generate intervention strategies, (6) support staff to implement interventions and (7) evaluate the effectiveness of the intervention using post-implementation clinical data. The theoretical and non-theoretical components of each trial arm will be distinguished in phases 4–5. Study outcomes include a LS referral process map for each hospital network, with evaluation of the proportion of patients with risk-appropriate completion of the LS referral pathway within 2 months of CRC resection pre and post implementation.

Discussion

This trial will determine the more effective approach for improving the detection of LS amongst patients with CRC, whilst also advancing understanding of the impact of theory-based implementation approaches in complex health systems and the feasibility of training healthcare professionals to use them. Insights gained will guide the development of future interventions to improve LS identification on a larger scale and across different contexts, as well as efforts to address the gap between evidence and practice in the rapidly evolving field of genomic research.

Trial registration

ANZCTR, ACTRN12618001072202. Registered on 27 June 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3457-6) contains supplementary material, which is available to authorized users.

Comprehensive geriatric assessment in Swedish acute geriatric settings

PURPOSE

Comprehensive geriatric assessment (CGA) is a widely used approach in geriatric care and involves multidisciplinary assessments focused on determining a frail elderly person's medical, psychological and functional capability to develop an integrated plan for treatment. The purpose of this paper is to describe and scrutinize the CGA implementation process at six acute geriatric departments in three county councils and to study the outcome by the documentation in the patient medical records, and the staff perceptions using CGA.

DESIGN/METHODOLOGY/APPROACH

The paper describes the implementation process stages. Outcome measures were based on patient medical records reviews at baseline and follow-ups at year 1 and year 2. Staff perceptions of using CGA were gathered by a questionnaire at the second follow-up.

FINDINGS

The implementation had not yet reached sustainability so the implementation process must continue. Results show that documentation on the different areas increased in year 1, as well as the use of standardized assessment tools. However, results from the reviews for year 2 showed some decrease. Staff considered CGA to have high value for the geriatric patient but pointed out the need for continuing education.

ORIGINALITY/VALUE

Successful strategies for this implementation were strong support from the managers, small seminars, CGA rounds, good introduction routines for new staff and the use of reminders such as pocket-sized focus cards. A high staff turnover occurred during the study, which probably had a significant negative impact on the results.

Implementation of provider payment system reforms in the age of universal health coverage: a realist review of evidence from Asian developing countries

Objective

Launched to assist in achieving universal health coverage, provider payment reform (PPR) is one of the most important policy tools deployed to transform incentives within a health system that is plagued with allocative inefficiency and high out-of-pocket payments to one that is able to deliver basic services and be cost-efficient. However, the black box of such reform – that is, the contexts in which reform operates, the mechanisms by which it changes health systems and behaviour within health systems, and the outcome patterns that arise from – remains unexplored. This review aims to examine the implementation mechanisms underlying PPR in Asian developing countries.

Methods

A realist synthesis approach was employed to tease out the configurative elements of PPR in developing countries. A multimethod and retrospective search was conducted to locate the evidence. A programme theory and data extraction framework were developed. Data were analysed using thematic synthesis to inform an overarching realist synthesis, expressed as a set of synthesized context-mechanism-outcome configurations.

Results

This review found that the policy design of PPR, policy capacity, willingness of policy adoption at the local government level and provider autonomy are critical contextual factors that could trigger different policy mechanisms leading to either intended theoretical outcomes or perverse incentives.

Conclusions

Our findings, demonstrating the PPR implementation contexts and mechanisms that have worked in Asian countries, have implications in terms of policy learning for most developing countries that are contemplating rolling out similar reforms in the future.

Early, specialist vocational rehabilitation to facilitate return to work after traumatic brain injury: the FRESH feasibility RCT

BACKGROUND

Up to 160,000 people incur traumatic brain injury (TBI) each year in the UK. TBI can have profound effects on many areas of human functioning, including participation in work. There is limited evidence of the clinical effectiveness and cost-effectiveness of vocational rehabilitation (VR) after injury to promote early return to work (RTW) following TBI.

OBJECTIVE

To assess the feasibility of a definitive, multicentre, randomised controlled trial (RCT) of the clinical effectiveness and cost-effectiveness of early, specialist VR plus usual care (UC) compared with UC alone on work retention 12 months post TBI.

DESIGN

A multicentre, feasibility, parallel-group RCT with a feasibility economic evaluation and an embedded mixed-methods process evaluation. Randomisation was by remote computer-generated allocation.

SETTING

Three NHS major trauma centres (MTCs) in England.

PARTICIPANTS

Adults with TBI admitted for > 48 hours and working or studying prior to injury.

INTERVENTIONS

Early specialist TBI VR delivered by occupational therapists (OTs) in the community using a case co-ordination model.

MAIN OUTCOME MEASURES

Self-reported RTW 12 months post randomisation, mood, functional ability, participation, work self-efficacy, quality of life and work ability. Feasibility outcomes included recruitment and retention rates. Follow-up was by postal questionnaires in two centres and face to face in one centre. Those collecting data were blind to treatment allocation.

RESULTS

Out of 102 target participants, 78 were recruited (39 randomised to each arm), representing 39% of those eligible and 5% of those screened. Approximately 2.2 patients were recruited per site per month. Of those, 56% had mild injuries, 18% had moderate injuries and 26% had severe injuries. A total of 32 out of 45 nominated carers were recruited. A total of 52 out of 78 (67%) TBI participants responded at 12 months (UC, n = 23; intervention, n = 29), completing 90% of the work questions; 21 out of 23 (91%) UC respondents and 20 out of 29 (69%) intervention participants returned to work at 12 months. Two participants disengaged from the intervention. Face-to-face follow-up was no more effective than postal follow-up. RTW was most strongly related to social participation and work self-efficacy. It is feasible to assess the cost-effectiveness of VR. Intervention was delivered as intended and valued by participants. Factors likely to affect a definitive trial include deploying experienced OTs, no clear TBI definition or TBI registers, and repatriation of more severe TBI from MTCs, affecting recruitment of those most likely to benefit/least likely to drop out.

LIMITATIONS

Target recruitment was not reached, but mechanisms to achieve this in future studies were identified. Retention was lower than expected, particularly in UC, potentially biasing estimates of the 12-month RTW rate.

CONCLUSIONS

This study met most feasibility objectives. The intervention was delivered with high fidelity. When objectives were not met, strategies to ensure feasibility of a full trial were identified. Future work should test two-stage recruitment and include resources to recruit from 'spokes'. A broader measure covering work ability, self-efficacy and participation may be a more sensitive outcome.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38581822.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 33. See the NIHR Journals Library website for further project information.

Social change agent training program tailored to occupational therapists' needs: a design-based study protocol

BACKGROUND

As social change agents (SCAs), occupational therapists (OTs) are expected to defend the rights of their clients, advocate for and with them, and try to influence organizational and political decision-makers. However, OTs do not generally feel equipped to take effective action. The overall goal of this research partnership is to support practising OTs in acquiring the knowledge and skills required to act as SCAs through a specific SCA training program and a toolkit that summarizes the key training points.

METHODS

The study will include three iterative phases (conceptualization, implementation and evaluation) and use a participatory process. The design of the training program and toolkit will draw on the expertise of the researchers (theoretical knowledge), a professional provincial partner and study participants (experiential knowledge). To evaluate the training program and toolkit, a self-administered evaluation questionnaire, facilitator observation grid and semi-structured guide designed to facilitate focus group discussions will be used. The quantitative and qualitative data will be analyzed using descriptive statistics and thematic analysis, respectively. The results of the initial implementation and evaluation phases will inform improvement of the training program and toolkit before starting the cycle with the following groups.

DISCUSSION

In addition to training about 100 OTs, this study will produce three main benefits: 1) development of two products, namely the SCA training program and toolkit, that are easy to reuse and potentially transferable to other professionals; 2) ownership of these products by the partner through its close involvement in all stages of the study; and 3) development of a sustainable partnership between a team of researchers and a recognized organization with networks across Canada and internationally. These three spin-offs will provide a solid basis for an increasing number of permanent implementation initiatives, in Québec and elsewhere in Canada, not just in occupational therapy but also in other professions.

How Should We Evaluate and Use Evidence to Improve Population Oral Health?

Generating and implementing evidence-based policy is an important aim for many publicly funded health systems. In dentistry, this is based on the assumption that evidence-based health care increases the efficiency and effectiveness of interventions to improve oral health at a population level. This article argues that a linear logic model that links the generation of research evidence with its use is overly simplistic. It also challenges an uncritical interpretation of the evidence-based paradigm and explores approaches to the evaluation of complex interventions and how they can be embedded into policy and practice to improve oral health at a population level.

Impact of an organization-wide knowledge translation strategy to support evidence-informed public health decision making

Background

The public health sector is moving toward adopting evidence-informed decision making into practice, but effort is still required to effectively develop capacity and promote contextual factors that advance and sustain it. This paper describes the impact of an organization-wide knowledge translation intervention delivered by knowledge brokers on evidence-informed decision making knowledge, skills and behaviour.

Methods

A case study design was implemented with the intervention and data collection tailored to the unique needs of each case (health department). A knowledge broker provided training workshops and mentored small groups through a seven step process of evidence-informed decision making. The intervention was delivered over 22 months; data related to evidence-informed decision making knowledge, skills and behaviour were collected at baseline and follow-up. Mixed effects regression models were developed to assess the impact of involvement in the intervention on the evidence-informed decision making outcomes.

Results

Data from a total of 606 health department staff were collected during baseline: 207 (33%) staff from Case A, 304 (28%) from Case B, and 95 (47%) from Case C. There were a total of 804 participants at follow-up: 258 (42%) from Case A, 391 from Case B (37%), and 155 (50%) from Case C. Statistically significant increases in knowledge and skills were observed overall, and in all three health departments. An increase in evidence-informed decision making behaviour was observed among those intensively involved in the intervention from all cases (statistically significant in Case A). The organizational characteristics of strategic priority, leadership, readiness, and choice of staff emerged as important factors in the change process.

Conclusions

Knowledge brokering is a promising organizational knowledge translation intervention to support evidence-informed decision making. The intervention appeared to have the greatest impact on those who became actively engaged with the knowledge broker in the intervention. Active participation in face-to-face training activities with a knowledge broker, focused specifically on evidence-informed decision making skill development, led to the greatest impact on associated behaviours, knowledge, and skills. Several organizational factors emerged as integral to success of the knowledge translation intervention.

It takes a village: a realist synthesis of social pediatrics program

OBJECTIVES

To better understand how social pediatric initiatives (SPIs) enact equitable, integrated, embedded approaches with high-needs children and families while facilitating proportionate distribution of health resources.

METHODS

The realist review method incorporated the following steps: (1) identifying the review question, (2) formulating the initial theory, (3) searching for primary studies, (4) selecting and appraising study quality, (5) synthesizing relevant data and (6) refining the theory.

RESULTS

Our analysis identified four consistent patterns of care that may be effective in social pediatrics: (1) horizontal partnerships based on willingness to share status and power; (2) bridged trust initiated through previously established third party relationships; (3) knowledge support increasing providers' confidence and skills for engaging community; and (4) increasing vulnerable families' self-reliance through empowerment strategies.

CONCLUSIONS

This research is unique because it focused on "how" outcomes are achieved and offers insight into the knowledge, skills and philosophical orientation clinicians need to effectively deliver care in SPIs. Research insights offer guidance for organizational leaders with a mandate to address child and youth health inequities and may be applicable to other health initiatives.

Facilitating Implementation of Research Evidence (FIRE): an international cluster randomised controlled trial to evaluate two models of facilitation informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework

BACKGROUND

Health care practice needs to be underpinned by high quality research evidence, so that the best possible care can be delivered. However, evidence from research is not always utilised in practice. This study used the Promoting Action on Research Implementation in Health Services (PARIHS) framework as its theoretical underpinning to test whether two different approaches to facilitating implementation could affect the use of research evidence in practice.

METHODS

A pragmatic clustered randomised controlled trial with embedded process and economic evaluation was used. The study took place in four European countries across 24 long-term nursing care sites, for people aged 60 years or more with documented urinary incontinence. In each country, sites were randomly allocated to standard dissemination, or one of two different types of facilitation. The primary outcome was the documented percentage compliance with the continence recommendations, assessed at baseline, then at 6, 12, 18, and 24 months after the intervention. Data were analysed using STATA15, multi-level mixed-effects linear regression models were fitted to scores for compliance with the continence recommendations, adjusting for clustering.

RESULTS

Quantitative data were obtained from reviews of 2313 records. There were no significant differences in the primary outcome (documented compliance with continence recommendations) between study arms and all study arms improved over time.

CONCLUSIONS

This was the first cross European randomised controlled trial with embedded process evaluation that sought to test different methods of facilitation. There were no statistically significant differences in compliance with continence recommendations between the groups. It was not possible to identify whether different types and "doses" of facilitation were influential within very diverse contextual conditions. The process evaluation (Rycroft-Malone et al., Implementation Science. doi: 10.1186/s13012-018-0811-0) revealed the models of facilitation used were limited in their ability to overcome the influence of contextual factors.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN11598502 . Date 4/2/10. The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007-2013) under grant agreement no. 223646.

A realist process evaluation within the Facilitating Implementation of Research Evidence (FIRE) cluster randomised controlled international trial: an exemplar

BACKGROUND

Facilitation is a promising implementation intervention, which requires theory-informed evaluation. This paper presents an exemplar of a multi-country realist process evaluation that was embedded in the first international randomised controlled trial evaluating two types of facilitation for implementing urinary continence care recommendations. We aimed to uncover what worked (and did not work), for whom, how, why and in what circumstances during the process of implementing the facilitation interventions in practice.

METHODS

This realist process evaluation included theory formulation, theory testing and refining. Data were collected in 24 care home sites across four European countries. Data were collected over four time points using multiple qualitative methods: observation (372 h), interviews with staff (n = 357), residents (n = 152), next of kin (n = 109) and other stakeholders (n = 128), supplemented by facilitator activity logs. A combined inductive and deductive data analysis process focused on realist theory refinement and testing.

RESULTS

The content and approach of the two facilitation programmes prompted variable opportunities to align and realign support with the needs and expectations of facilitators and homes. This influenced their level of confidence in fulfilling the facilitator role and ability to deliver the intervention as planned. The success of intervention implementation was largely dependent on whether sites prioritised their involvement in both the study and the facilitation programme. In contexts where the study was prioritised (including release of resources) and where managers and staff support was sustained, this prompted collective engagement (as an attitude and action). Internal facilitators' (IF) personal characteristics and abilities, including personal and formal authority, in combination with a supportive environment prompted by managers triggered the potential for learning over time. Learning over time resulted in a sense of confidence and personal growth, and enactment of the facilitation role, which resulted in practice changes.

CONCLUSION

The scale and multi-country nature of this study provided a novel context to conduct one of the few trial embedded realist-informed process evaluations. In addition to providing an explanatory account of implementation processes, a conceptual platform for future facilitation research is presented. Finally, a realist-informed process evaluation framework is outlined, which could inform future research of this nature.

TRIAL REGISTRATION

Current controlled trials ISRCTN11598502 .

NHS managers’ use of nursing workforce planning and deployment technologies: a realist synthesis

Background

Policy and reviews of health-care safety and quality emphasise the role of NHS managers in ensuring safe, good-quality patient care through effective staffing. Guidance requires that NHS managers combine professional judgement with evidence-based workforce planning and deployment tools and technologies (WPTs). Evidence has focused on the effectiveness of WPTs, but little is known about supporting their implementation, or the impact of using WPTs across settings.

Objectives

The review answered the following question: ‘NHS managers’ use of workforce planning and deployment technologies and their impacts on nursing staffing and patient care: what works, for whom, how and in what circumstances?’.

Design

A realist synthesis was conducted. A programme theory was formulated and expressed as hypotheses in the form of context, mechanisms and outcomes; this considered how, through using WPTs, particular conditions produced responses to generate outcomes. There were four phases: (1) development of a theoretical territory to understand nurse workforce planning and deployment complexity, resulting in an initial programme theory; (2) retrieval, review and synthesis of evidence, guided by the programme theory; (3) testing and refinement of the programme theory for practical application; and (4) actionable recommendations to support NHS managers in the implementation of WPTs for safe staffing.

Participants

NHS managers, patient and public representatives and policy experts informed the programme theory in phase 1, which was validated in interviews with 10 NHS managers. In phase 3, 11 NHS managers were interviewed to refine the programme theory.

Results

Workforce planning and deployment tools and technologies can be characterised functionally by their ability to summarise and aggregate staffing information, communicate about staffing, allocate staff and facilitate compliance with standards and quality assurance. NHS managers need to combine local knowledge and professional judgement with data from WPTs for effective staffing decisions. WPTs are used in a complex workforce system in which proximal factors (e.g. the workforce satisfaction with staffing) can influence distal factors (e.g. organisational reputation and potential staff recruitment). The system comprises multiple organisational strategies (e.g. professional and financial), which may (or may not) align around effective staffing. The positive impact of WPTs can include ensuring that staff are allocated effectively, promoting the patient safety agenda within an organisation, learning through comparison about ‘what works’ in effective staffing and having greater influence in staffing work. WPTs appear to have a positive impact when they visibly integrate data on needs and resources and when there is technical and leadership support. A collaborative process appears to be best for developing and implementing WPTs, so that they are fit for purpose.

Limitations

The evidence, predominantly from acute care, often lacked detail on how managers applied professional judgement to WPTs for staffing decisions. The evidence lacked specificity about how managers develop skills on communicating staffing decisions to patients and the public.

Conclusions and recommendations

The synthesis produced initial explanations of the use and impact of WPTs for decision-making and what works to support NHS managers to use these effectively. It is suggested that future research should further evaluate the programme theory.

Study registration

This study is registered as PROSPERO CRD42016038132.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Managerial leadership for research use in nursing and allied health care professions: a systematic review

Background

Leadership by point-of-care and senior managers is increasingly recognized as critical to the acceptance and use of research evidence in practice. The purpose of this systematic review was to identify the leadership behaviours of managers that are associated with research use by clinical staff in nursing and allied health professionals.

Methods

A mixed methods systematic review was performed. Eight electronic bibliographic databases were searched. Studies examining the association between leadership behaviours and nurses and allied health professionals’ use of research were eligible for inclusion. Studies were excluded if leadership could not be clearly attributed to someone in a management position. Two reviewers independently screened abstracts, reviewed full-text articles, extracted data and performed quality assessments. Narrative synthesis was conducted.

Results

The search yielded 7019 unique titles and abstracts after duplicates were removed. Three hundred five full-text articles were reviewed, and 31 studies reported in 34 articles were included. Methods used were qualitative (n = 19), cross-sectional survey (n = 9), and mixed methods (n = 3). All studies included nurses, and six also included allied health professionals. Twelve leadership behaviours were extracted from the data for point-of-care managers and ten for senior managers. Findings indicated that managers performed a diverse range of leadership behaviours that encompassed change-oriented, relation-oriented and task-oriented behaviours. The most commonly described behavior was support for the change, which involved demonstrating conceptual and operational commitment to research-based practices.

Conclusions

This systematic review adds to the growing body of evidence that indicates that manager-staff dyads are influential in translating research evidence into action. Findings also reveal that leadership for research use involves change and task-oriented behaviours that influence the environmental milieu and the organisational infrastructure that supports clinical care. While findings explain how managers enact leadership for research use, we now require robust methodological studies to determine which behaviours are effective in enabling research use with nurses and allied health professionals for high-quality evidence-based care.

Trial registration

PROSPERO CRD42014007660

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0817-7) contains supplementary material, which is available to authorized users.

How do clinicians use implementation tools to apply breast cancer screening guidelines to practice?

Background

Implementation tools (iTools) may enhance uptake of guidelines. However, little evidence exists on their use by primary care clinicians. This study explored which iTools clinicians used and how often; how satisfied clinicians were with the tools; whether tool use was associated with practice changes; and identified mediators for practice change(s) related to breast cancer screening (BCS).

Methods

Canadian primary care providers who are members of the Practice-Based Small Group Learning Program (n = 1464) were invited to participate in this mixed methods study. An educational module was discussed in a small group learning context, and data collection included an on-line survey, practice reflection tools (PRTs), and interviews. The module included both the Canadian Task Force on Preventive Health Care revised guideline on BCS and iTools for clinician and/or patient use. After discussing the module and at 3 months, participants completed PRTs identifying their planned practice change(s) and documenting implementation outcome(s). Use of the iTools was explored via online survey and individual interviews.

Results

Seventy participants agreed to participate. Of these, 48 participated in the online survey, 43 completed PRTs and 14 were interviewed. Most survey participants (77%) reported using at least one of seven tools available for implementing BCS guideline. Of these (78%) reported using more than one tool. Almost all participants used tools for clinicians (92%) and 62% also used tools for patients. As more tools were used, more practice changes were reported on the survey and PRTs. Interviews provided additional findings. Once information from an iTool was internalized, there was no further need for the tool. Participants did not use tools (23%) due to disagreements with the BCS guideline, patients’ expectations, and/or experiences with diagnosis of breast cancer.

Conclusion

This study found that clinicians use tools to implement practice changes related to BCS guideline. Tools developed for clinicians were used to understand and consolidate the recommendations before tools to be used with patients were employed to promote decision-making. Mediating factors that impacted tool use confirmed previous research. Finally, use of some iTools decreased over time because information was internalized.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0765-2) contains supplementary material, which is available to authorized users.

What can we learn from interventions that aim to increase policy-makers' capacity to use research? A realist scoping review

Background

Health policy-making can benefit from more effective use of research. In many policy settings there is scope to increase capacity for using research individually and organisationally, but little is known about what strategies work best in which circumstances. This review addresses the question: What causal mechanisms can best explain the observed outcomes of interventions that aim to increase policy-makers’ capacity to use research in their work?

Methods

Articles were identified from three available reviews and two databases (PAIS and WoS; 1999–2016). Using a realist approach, articles were reviewed for information about contexts, outcomes (including process effects) and possible causal mechanisms. Strategy + Context + Mechanism = Outcomes (SCMO) configurations were developed, drawing on theory and findings from other studies to develop tentative hypotheses that might be applicable across a range of intervention sites.

Results

We found 22 studies that spanned 18 countries. There were two dominant design strategies (needs-based tailoring and multi-component design) and 18 intervention strategies targeting four domains of capacity, namely access to research, skills improvement, systems improvement and interaction. Many potential mechanisms were identified as well as some enduring contextual characteristics that all interventions should consider. The evidence was variable, but the SCMO analysis suggested that tailored interactive workshops supported by goal-focused mentoring, and genuine collaboration, seem particularly promising. Systems supports and platforms for cross-sector collaboration are likely to play crucial roles. Gaps in the literature are discussed.

Conclusion

This exploratory review tentatively posits causal mechanisms that might explain how intervention strategies work in different contexts to build capacity for using research in policy-making.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0277-1) contains supplementary material, which is available to authorized users.

Hospital-based interventions: a systematic review of staff-reported barriers and facilitators to implementation processes

BACKGROUND

Translation of evidence-based interventions into hospital systems can provide immediate and substantial benefits to patient care and outcomes, but successful implementation is often not achieved. Existing literature describes a range of barriers and facilitators to the implementation process. This systematic review identifies and explores relationships between these barriers and facilitators to highlight key domains that need to be addressed by researchers and clinicians seeking to implement hospital-based, patient-focused interventions.

METHODS

We searched MEDLINE, PsychInfo, Embase, Web of Science, and CINAHL using search terms focused specifically on barriers and facilitators to the implementation of patient-focused interventions in hospital settings. To be eligible, papers needed to have collected formal data (qualitative or quantitative) that specifically assessed the implementation process, as experienced by the staff involved.

RESULTS

Of 4239 papers initially retrieved, 43 papers met inclusion criteria. Staff-identified barriers and facilitators to implementation were grouped into three main domains: system, staff, and intervention. Bi-directional associations were evident between these domains, with the strongest links evident between staff and intervention.

CONCLUSIONS

Researchers and health professionals engaged in designing patient-focused interventions need to consider barriers and facilitators across all three identified domains to increase the likelihood of implementation success. The interrelationships between domains are also crucial, as resources in one area can be leveraged to address barriers in others. These findings emphasize the importance of careful intervention design and pre-implementation planning in response to the specific system and staff context in order to increase likelihood of effective and sustainable implementation.

TRIAL REGISTRATION

This review was registered on the PROSPERO database: CRD42017057554  in February 2017.

An ethnographic observation study of the facilitator role in an implementation process

Background

Even though the importance of a facilitator during an implementation process is well described, the facilitator’s role is rarely problematized in relation to the organizational context in terms of power and legitimacy; themes which have recently been brought to the fore when studying change in health care organizations. Therefore, in this article, we present a qualitative study with the aim of identifying key aspects of the experience of being in a facilitator role. The data collection involved ethnographic fieldwork encompassing observations and field notes, as well as two qualitative interviews with the facilitator. The data were analysed using a phenomenological hermeneutical method in order to formulate thematic aspects of the implementation process. The study was conducted in southern Sweden between January 2013 and August 2014.

Results

One main theme, “walking a tightrope”, and four sub-themes, all of which involved balancing acts of different levels and different ways, were identified. These included: being in control, but needing to adjust; pushing for change, but forced to stand back; being accepted, but dependent; and being reasonable, but culturally sensitive.

Conclusion

Instead of listing the desirable qualities and conditions of a facilitator, this study shows that being a facilitator can be described more completely by applying the concept of role, thus allowing a more holistic process of reflection and analysis. This in turn makes it possible to move from the reactive stance of balancing to a more proactive stance of negotiating.

Core Competencies or a Competent Core? A Scoping Review and Realist Synthesis of Invasive Bedside Procedural Skills Training in Internal Medicine

PURPOSE

Invasive bedside procedures are core competencies for internal medicine, yet no formal training guidelines exist. The authors conducted a scoping review and realist synthesis to characterize current training for lumbar puncture, arthrocentesis, paracentesis, thoracentesis, and central venous catheterization. They aimed to collate how educators justify using specific interventions, establish which interventions have the best evidence, and offer directions for future research and training.

METHOD

The authors systematically searched Medline, Embase, the Cochrane Library, and ERIC through April 2015. Studies were screened in three phases; all reviews were performed independently and in duplicate. The authors extracted information on learner and patient demographics, study design and methodological quality, and details of training interventions and measured outcomes. A three-step realist synthesis was performed to synthesize findings on each study's context, mechanism, and outcome, and to identify a foundational training model.

RESULTS

From an initial 6,671 studies, 149 studies were further reduced to 67 (45%) reporting sufficient information for realist synthesis. Analysis yielded four types of procedural skills training interventions. There was relative consistency across contexts and significant differences in mechanisms and outcomes across the four intervention types. The medical procedural service was identified as an adaptable foundational training model.

CONCLUSIONS

The observed heterogeneity in procedural skills training implies that programs are not consistently developing residents who are competent in core procedures. The findings suggest that researchers in education and quality improvement will need to collaborate to design training that develops a "competent core" of proceduralists using simulation and clinical rotations.