Tool for evaluating research implementation challenges: a sense-making protocol for addressing implementation challenges in complex research settings

[From evidence to practice: The Disemination and Implementation Science in primary care]

Dissemination and Implementation Science focuses on bridging the gap between scientific research and its practical application in the real world. By identifying and promoting effective strategies, the Science of Dissemination and Implementation disseminates and implements evidence-based interventions in healthcare settings, taking into account the needs, barriers, context, resources, and end users. This special article introduces and debates the most recent advances in this field, highlighting key approaches, theoretical frameworks, as well as specific challenges and opportunities applied to primary and community care. Additionally, concrete examples tailored to the Spanish context are presented. Given the nascent state of the use of the Dissemination and Implementation Science in Spain, the authors recommend strategically adopting this approach and its principles in primary and community care to expedite the adoption of effective interventions that promote health.

Where is "policy" in dissemination and implementation science? Recommendations to advance theories, models, and frameworks: EPIS as a case example

BACKGROUND

Implementation science aims to accelerate the public health impact of evidence-based interventions. However, implementation science has had too little focus on the role of health policy - and its inseparable politics, polity structures, and policymakers - in the implementation and sustainment of evidence-based healthcare. Policies can serve as determinants, implementation strategies, the evidence-based "thing" to be implemented, or another variable in the causal pathway to healthcare access, quality, and patient outcomes. Research describing the roles of policy in dissemination and implementation (D&I) efforts is needed to resolve persistent knowledge gaps about policymakers' evidence use, how evidence-based policies are implemented and sustained, and methods to de-implement policies that are ineffective or cause harm. Few D&I theories, models, or frameworks (TMF) explicitly guide researchers in conceptualizing where, how, and when policy should be empirically investigated. We conducted and reflected on the results of a scoping review to identify gaps of existing Exploration, Preparation, Implementation, and Sustainment (EPIS) framework-guided policy D&I studies. We argue that rather than creating new TMF, researchers should optimize existing TMF to examine policy's role in D&I. We describe six recommendations to help researchers optimize existing D&I TMF. Recommendations are applied to EPIS, as one example for advancing TMF for policy D&I.

RECOMMENDATIONS

(1) Specify dimensions of a policy's function (policy goals, type, contexts, capital exchanged). (2) Specify dimensions of a policy's form (origin, structure, dynamism, outcomes). (3) Identify and define the nonlinear phases of policy D&I across outer and inner contexts. (4) Describe the temporal roles that stakeholders play in policy D&I over time. (5) Consider policy-relevant outer and inner context adaptations. (6) Identify and describe bridging factors necessary for policy D&I success.

CONCLUSION

Researchers should use TMF to meaningfully conceptualize policy's role in D&I efforts to accelerate the public health impact of evidence-based policies or practices and de-implement ineffective and harmful policies. Applying these six recommendations to existing D&I TMF advances existing theoretical knowledge, especially EPIS application, rather than introducing new models. Using these recommendations will sensitize researchers to help them investigate the multifaceted roles policy can play within a causal pathway leading to D&I success.

What Kind of Interventions Were Perceived as Effective Against Coronavirus-19 in Nursing Homes in Italy? A Descriptive Qualitative Study

Purpose

To identify interventions implemented during the first, second and third waves of the Coronavirus disease 2019 (COVID-19) among Italian Nursing Homes (NHs).

Patients and Methods

A descriptive qualitative design according to COnsolidated criteria for REporting Qualitative (COREQ) guideline. A purposeful sample of five public NHs, located in the north-east of Italy, equipped with from 60 to 151 beds, participated. Six nurse managers, four clinical nurses and one NH director were interviewed in depth at the end of 2021. These interviews were audio-recorded and then transcribed verbatim. A qualitative content analysis was performed to identify effective interventions as perceived by participants to protect facilities and residents from the pandemic.

Results

Three main sets of interventions have been applied, at the environmental, nurse staff and at the resident levels. Some have been enacted in all facilities, others in a few but in a homogeneous fashion, while other interventions have been implemented in some NHs also in contrast with available national or local recommendations.

Conclusion

Despite their documented frailty and precarious system, NHs implemented several interventions to protect their residents from the COVID-19. All interventions have been designed and implemented during the event, suggesting the need to increase the NHs’ preparedness to face future disasters. Regarding those interventions enacted in contrast to the recommendations or not homogeneously across NHs, future investigations are suggested to assess their actual effectiveness and accumulate evidence for the future.

The Influence of Context on Implementation and Improvement: Protocol for a Mixed Methods, Secondary Analyses Study

BACKGROUND

Caring for the well-being of older adults is one of the greatest challenges in modern societies. Improving the quality of care and life for older adults and the work lives of their care providers calls for effective knowledge translation of evidence-based best practices.

OBJECTIVE

This study's purpose is to contribute to knowledge translation by better understanding the roles of organizational context (workplace environment) and facilitation (process or role) in implementation and improvement success. Our study has 2 goals: (1) to advance knowledge translation science by further developing and testing the Promoting Action on Research Implementation in Health Services framework (which outlines how implementation relies on the interplay of context, facilitation, and evidence) and (2) to advance research by optimizing implementation success via tailoring of modifiable elements of organizational context and facilitation.

METHODS

This is secondary analyses of 15 years of longitudinal data from the Translating Research in Elder Care (TREC) program's multiple data sources. This research is ongoing in long-term care (LTC) homes in western Canada. TREC data include the following: 5 waves of survey collection, 2 clinical trials, and regular ongoing outcome data for LTC residents. We will use a sequential exploratory and confirmatory mixed methods design. We will analyze qualitative and quantitative data holdings in an iterative process: (1) comprehensive reanalysis of qualitative data to derive hypotheses, (2) quantitative modeling to test hypotheses, and (3) action cycles to further refine and integrate qualitative and quantitative analyses. The research team includes 4 stakeholder panels: (1) system decision- and policy makers, (2) care home managers, (3) direct care staff, and (4) a citizen engagement group of people living with dementia and family members of LTC residents. A fifth group is our panel of external scientific advisors. Each panel will engage periodically, providing their perspectives on project direction and findings.

RESULTS

This study is funded by the Canadian Institutes of Health Research. Ethics approval was obtained from the University of Alberta (Pro00096541). The results of the secondary analyses are expected by the end of 2023.

CONCLUSIONS

The project will advance knowledge translation science by deepening our understanding of the roles of context, the interactions between context and facilitation, and their influence on resident and staff quality outcomes. Importantly, findings will inform understanding of the mechanisms by which context and facilitation affect the success of implementation and offer insights into factors that influence the implementation success of interventions in nursing homes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40611.

Adapting a social network intervention for use in secondary mental health services using a collaborative approach with service users, carers/supporters and health professionals in the United Kingdom

Background

Social integration, shared decision-making and personalised care are key elements of mental health and social care policy. Although these elements have been shown to improve service user and service-level outcomes, their translation into practice has been inconsistent and social isolation amongst service users persists.

Aim

To co-adapt, with service users, carers/supporters and health professionals, a web-based social network intervention, GENIE™, for use in secondary mental health services. The intervention is designed to support social activity and preference discussions between mental healthcare professionals and service users as a means of connecting individuals to local resources.

Methods

In Phase 1 (LEARN), we completed two systematic reviews to synthesise the existing evidence relating to the i) effectiveness and ii) the implementation of social network interventions for people with mental health difficulties. We undertook semi-structured interviews with a convenience sample of 15 stakeholders previously involved in the implementation of the intervention in physical healthcare settings. Interviews were also conducted with 5 national key stakeholders in mental health (e.g., policy makers, commissioners, third sector leads) to explore wider implementation issues.

In Phase 2 (ADAPT), we worked iteratively with eight service users, nine carers, six professionals/volunteers and our patient and public advisory group. We drew on a framework for experience-based co-design, consisting of a series of stakeholder consultation events, to discuss the use of the social network intervention, in mental health services. Participants also considered factors that could serve as enablers, barriers, and challenges to local implementation.

Results

Across the stakeholder groups there was broad agreement that the social network intervention had potential to be useful within mental health services. In terms of appropriate and effective implementation, such an intervention was predicted to work best within the care planning process, on discharge from hospital and within early intervention services. There were indications that the social connection mapping and needs assessment components were of most value and feasible to implement which points to the potential utility of a simplified version compared to the one used in this study. The training provided to facilitators was considered to be more important than their profession and there were indications that service users should be offered the opportunity to invite a carer, friend, or family member to join them in the intervention.

Conclusion

The GENIE™ intervention has been co-adapted for use in mental health services and a plan for optimal implementation has been co-produced. The next phase of the programme of work is to design and implement a randomised controlled trial to evaluate clinical and cost effectiveness of a simplified version of the intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08521-1.

Barriers and enablers to leisure provision in residential aged care: personal care attendant perspectives

This exploratory descriptive study investigated barriers and enablers to the provision of leisure activities for people living in three Australian residential aged care facilities (RACFs) that operated under a household model of care. This research is unique in the international context, as few studies have explored the understandings and experiences of personal care attendants' (PCAs) perceptions of what impacts leisure provision for people living in RACFs. Qualitative data were collected from 17 PCAs via four focus groups. Barriers to leisure provision were identified as PCA–resident ratios, competing demands of the PCA role and a prioritisation of physical care tasks over leisure-related activities. The severity of residents' dementia (cognitive and functional deficits) as well as behavioural and psychological symptoms of dementia were also framed as barriers to participation in and the provision of leisure. Participants identified enablers of leisure provision as related to perceptions of leisure, the experiential knowledge of staff, organisational support and resourcing. The study findings suggest that enhancing leisure provision for people living with dementia will require attention to system issues (i.e. staffing levels, ratios, PCA role demands) as well as PCA knowledge and capability to facilitate person-centred leisure.

Perceived Factors of Influence on the Implementation of a Multidimensional Project to Improve Patients' Movement Behavior During Hospitalization: A Qualitative Study

OBJECTIVE

The aim of this study was to explore perceived factors of influence on the implementation of Hospital in Motion, a multidimensional and multidisciplinary implementation project to improve inpatients' movement behavior.

METHODS

This qualitative study was conducted on 4 wards. Per ward, a tailored action plan was implemented consisting of multiple tools and interventions to stimulate the integration of inpatient physical activity in usual care processes. After implementation, semi-structured interviews were performed with health care professionals and patients to explore perceived factors of influence on the implementation of the Hospital in Motion project. A content analysis was performed using the framework of the Medical Research Council for complex interventions as guidance for the identification of categories and themes.

RESULTS

In total, 16 interviews were conducted with health care professionals and 12 with patients. The results were categorized into the 3 key components of the Medical Research Council framework: implementation, mechanisms of impact, and context. An important factor of influence within the theme "implementation" was the iterative and multidisciplinary approach. Within the theme "mechanisms of impact," continuous attention and the interaction of multiple interventions, tailored to the target group and targeting multiple dimensions (individual, inter-professional, community and society), were perceived as important. Within the theme "context," the intrinsic motivation and inter-professional, community and societal culture towards physical activity was perceived to be of influence.

CONCLUSION

Impact can be achieved and maintained by creating continuous attention to inpatient physical activity and by the interaction between different interventions and dimensions during implementation. To maintain enough focus, the amount of activities at one time should be limited.

IMPACT

To improve inpatients' movement behavior, implementation project teams should be multidisciplinary and should implement a small set of tailored interventions that target multiple dimensions. Intermediate evaluation of the implementation process, strategies, and interventions is recommended.

Missed nursing care and complexity theory: a conceptual paper

Background

Missed nursing care is a complex healthcare problem. Extant literature in this area identifies several interventions that can be used in acute hospital settings to minimise the impact of missed nursing care. However, controversy still exists as to the effectiveness of these interventions on reducing the occurrence of missed nursing care.

Aim

This theoretical paper aimed to provide a conceptual understanding of missed nursing care using complexity theory.

Methods

The method utilised for this paper is based on a literature review on missed care and complexity theory in healthcare.

Results

We found that the key virtues of complexity theory relevant to the missed nursing care phenomenon were adaptation and self-organisation, non-linear interactions and history. It is suggested that the complex adaptive systems approach may be more useful for nurse managers to inform and prepare nurses to meet uncertain encounters in their everyday clinical practice and therefore reduce instances of missed care.

Conclusions

This paper envisions that it is time that methods used to explore missed care changed. Strategies proposed in this paper may have an important impact on the ability of nursing staff to provide quality and innovative healthcare in the modern healthcare system.

Multi-tiered external facilitation: the role of feedback loops and tailored interventions in supporting change in a stepped-wedge implementation trial

BACKGROUND

Facilitation is a complex, relational implementation strategy that guides change processes. Facilitators engage in multiple activities and tailor efforts to local contexts. How this work is coordinated and shared among multiple, external actors and the contextual factors that prompt and moderate facilitators to tailor activities have not been well-described.

METHODS

We conducted a mixed methods evaluation of a trial to improve the quality of transient ischemic attack care. Six sites in the Veterans Health Administration received external facilitation (EF) before and during a 1-year active implementation period. We examined how EF was employed and activated. Data analysis included prospective logs of facilitator correspondence with sites (160 site-directed episodes), stakeholder interviews (a total of 78 interviews, involving 42 unique individuals), and collaborative call debriefs (n=22) spanning implementation stages. Logs were descriptively analyzed across facilitators, sites, time periods, and activity types. Interview transcripts were coded for content related to EF and themes were identified. Debriefs were reviewed to identify instances of and utilization of EF during site critical junctures.

RESULTS

Multi-tiered EF was supported by two groups (site-facing quality improvement [QI] facilitators and the implementation support team) that were connected by feedback loops. Each site received an average of 24 episodes of site-directed EF; most of the EF was delivered by the QI nurse. For each site, site-directed EF frequently involved networking (45%), preparation and planning (44%), process monitoring (44%), and/or education (36%). EF less commonly involved audit and feedback (20%), brainstorming solutions (16%), and/or stakeholder engagement (5%). However, site-directed EF varied widely across sites and time periods in terms of these facilitation types. Site participants recognized the responsiveness of the QI nurse and valued her problem-solving, feedback, and accountability support. External facilitators used monitoring and dialogue to intervene by facilitating redirection during challenging periods of uncertainty about project direction and feasibility for sites. External facilitators, in collaboration with the implementation support team, successfully used strategies tailored to diverse local contexts, including networking, providing data, and brainstorming solutions.

CONCLUSIONS

Multi-tiered facilitation capitalizing on emergent feedback loops allowed for tailored, site-directed facilitation. Critical juncture cases illustrate the complexity of EF and the need to often try multiple strategies in combination to facilitate implementation progress.

TRIAL REGISTRATION

The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) is a registered trial ( NCT02769338 ), May 11, 2016-prospectively registered.

Process evaluation of a bio-behavioural HIV research combined with prevention among GBMSM in 13 European countries

Comparative European data using Second Generation Surveillance System (SGSS) are scarce among gay, bisexual and other men who have sex with men. This study evaluated the implementation of Sialon II, a bio-behavioural HIV research combined with targeted HIV prevention in 13 European cities conducted in collaboration with community partners. A mixed-methods process evaluation assessed the project's coverage, outputs, quality, challenges and opportunities for improvement. Data collected through structured questionnaire from 71 data collectors from community-based organisations and semi-structured interviews with 17 managers of participating gay venues were analysed. Overall implementation was successful, achieving 4901 valid behavioural questionnaires and obtaining 4716 biological samples. Challenges in conducting bio-behavioural research in gay venues related to strict research protocols and unfavourable characteristics of venues. Formative research, collaboration with community gay venues, and offering HIV prevention emerged as facilitators. Community researchers' training was crucial for fidelity to research protocols, increased trust amongst communities and enabled data collectors to effectively address practical problems in the field. Scientifically sound SGSS with community participation is feasible and allows for including 'hard-to-reach' populations. Prevention benefits include awareness raising, capacity building and sexual health promotion in gay venues. The findings are beneficial for epidemiological research among other HIV key populations.

Designing and undertaking randomised implementation trials: guide for researchers

Implementation science is the study of methods to promote the systematic uptake of evidence based interventions into practice and policy to improve health. Despite the need for high quality evidence from implementation research, randomised trials of implementation strategies often have serious limitations. These limitations include high risks of bias, limited use of theory, a lack of standard terminology to describe implementation strategies, narrowly focused implementation outcomes, and poor reporting. This paper aims to improve the evidence base in implementation science by providing guidance on the development, conduct, and reporting of randomised trials of implementation strategies. Established randomised trial methods from seminal texts and recent developments in implementation science were consolidated by an international group of researchers, health policy makers, and practitioners. This article provides guidance on the key components of randomised trials of implementation strategies, including articulation of trial aims, trial recruitment and retention strategies, randomised design selection, use of implementation science theory and frameworks, measures, sample size calculations, ethical review, and trial reporting. It also focuses on topics requiring special consideration or adaptation for implementation trials. We propose this guide as a resource for researchers, healthcare and public health policy makers or practitioners, research funders, and journal editors with the goal of advancing rigorous conduct and reporting of randomised trials of implementation strategies.

Fidelity challenges while implementing an intervention aimed at increasing eating performance among nursing home residents with cognitive decline: A multicentre, qualitative descriptive study design

AIMS AND OBJECTIVES

To increase the knowledge on fidelity challenges in intervention studies promoting eating independence in residents with cognitive decline living in nursing homes (NHs).

BACKGROUND

A few studies have documented to date factors affecting fidelity in intervention studies performed in NH settings. Moreover, fidelity issues in intervention studies aimed at promoting eating independence among NH residents with cognitive decline have not been studied to date.

DESIGN

A hybrid study design was performed in 2018 and reported here according to the COnsolidated criteria for REporting Qualitative research.

METHODS

In a clustered multicentre before/after intervention study design, a nested, multicentre qualitative descriptive design was performed. Four researchers with a nursing background, who received appropriate training, implemented the designed intervention. This consisted in intentional rounds in the dining rooms during lunchtime and was based on supportive, prescriptive and informative prompts delivered to residents with cognitive decline aimed at stimulating eating independence. A momentary assessment method was used, based on daily diary filled in by participant researchers after every session of intervention delivery on the following five dimensions of fidelity: (a) adherence, (b) dose (or exposure), (c) intervention quality, (d) participant responsiveness and (e) programme differentiation. A direct content analysis of the narratives reported on the diaries was performed.

RESULTS

Factors increasing or hindering intervention fidelity during its implementation emerged at the NH, staff, family caregivers, resident, researchers and at the intervention itself levels.

CONCLUSIONS

Several factors emerged and all reported potentially both positive and negative influences on fidelity while implementing an intervention aimed at promoting eating independence among NH residents. Fidelity challenges should be considered as dynamic in NH intervention studies, where continuous adjustments of the intervention delivered are required.

RELEVANCE TO CLINICAL PRACTICE

A calm environment, with staff members showing a caring behaviour, and researchers having achieved good familiarity with the NH setting, the residents, their family carers and the staff members, can all increase intervention fidelity.

A scoping review of complexity science in nursing

AIM

To describe how complexity science has been integrated into nursing.

DESIGN

A scoping review.

DATA SOURCE/REVIEW METHOD

Academic Search Elite, Scopus, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, PubMed and Web of Science were searched November 2016, updated in October 2017 and January 2020. The working process included: problem identification, literature search, data evaluation, synthesizing and presentation.

RESULTS

Four categories were found in the included 89 articles: (a) how complexity science is integrated into the nursing literature in relation to nursing education and teaching; (b) patients' symptoms, illness outcome and safety as characteristics of complexity science in nursing; (c) that leaders and managers should see organizations as complex and adaptive systems, rather than as linear machines; and (d) the need for a novel approach to studying complex phenomena such as healthcare organizations. Lastly, the literature explains how complexity science has been incorporated into the discourse in nursing and its development.

CONCLUSION

The review provided strong support for use in complexity science in the contemporary nursing literature. Complexity science is also highly applicable and relevant to clinical nursing practice and nursing management from an organizational perspective. The application of complexity science as a tool in the analysis of complex nursing systems could improve our understanding of effective interactions among patients, families, physicians and hospital and skilled nursing facility staff as well as of education.

IMPACT

Understanding complexity science in relation to the key role of nurses in the healthcare environment can improve nursing work and nursing theory development. The use of complexity science provides nurses with a language that liberates them from the reductionist view on nursing education, practice and management.

Enhancing patient and organizational readiness for cardiovascular risk reduction among Black and Latinx patients living with HIV: Study protocol

Cardiovascular disease (CVD) is an increasingly important cause of morbidity and mortality among people living with HIV (PLWH) now that HIV is a manageable chronic disease. Identification and treatment of comorbid medical conditions for PLWH, including CVD and its risk factors, typically lack a critical component of care: integrated care for histories of trauma. Experiences of trauma are associated with increased HIV infection, CVD risk, inconsistent treatment adherence, and poor CVD outcomes. To address this deficit among those at greatest risk and disproportionately affected by HIV and trauma-i.e., Black and Latinx individuals-a novel culturally-congruent, evidence-informed care model, "Healing our Hearts, Minds and Bodies" (HHMB), has been designed to address patients' trauma histories and barriers to care, and to prepare patients to engage in CVD risk reduction. Further, in recognition of the need to ensure that PLWH receive guideline-concordant cardiovascular care, implementation strategies have been identified that prepare providers and clinics to address CVD risk among their Black and Latinx PLWH. The focus of this paper is to describe the hybrid Type 2 effectiveness/implementation study design, the goal of which is to increase both patient and organizational readiness to address trauma and CVD risk among 260 Black and Latinx PLWH recruited from two HIV service organizations in Southern California. This study is expected to produce important information regarding the value of the HHMB intervention and implementation processes and strategies designed for use in implementing HHMB and other evidence-informed programs in diverse, resource-constrained treatment settings, including those that serve patients living in deep poverty. Clinical trials registry: NCT04025463.

Setting Priorities to Inform Assessment of Care Homes' Readiness to Participate in Healthcare Innovation: A Systematic Mapping Review and Consensus Process

Organisational context is known to impact on the successful implementation of healthcare initiatives in care homes. We undertook a systematic mapping review to examine whether researchers have considered organisational context when planning, conducting, and reporting the implementation of healthcare innovations in care homes. Review data were mapped against the Alberta Context Tool, which was designed to assess organizational context in care homes. The review included 56 papers. No studies involved a systematic assessment of organisational context prior to implementation, but many provided post hoc explanations of how organisational context affected the success or otherwise of the innovation. Factors identified to explain a lack of success included poor senior staff engagement, non-alignment with care home culture, limited staff capacity to engage, and low levels of participation from health professionals such as general practitioners (GPs). Thirty-five stakeholders participated in workshops to discuss findings and develop questions for assessing care home readiness to participate in innovations. Ten questions were developed to initiate conversations between innovators and care home staff to support research and implementation. This framework can help researchers initiate discussions about health-related innovation. This will begin to address the gap between implementation theory and practice.

Periodic reflections: a method of guided discussions for documenting implementation phenomena

BACKGROUND

Ethnography has been proposed as a valuable method for understanding how implementation occurs within dynamic healthcare contexts, yet this method can be time-intensive and challenging to operationalize in pragmatic implementation. The current study describes an ethnographically-informed method of guided discussions developed for use by a multi-project national implementation program.

METHODS

The EMPOWER QUERI is conducting three projects to implement innovative care models in VA women's health for high-priority health concerns - prediabetes, cardiovascular risk, and mental health - utilizing the Replicating Effective Programs (REP) implementation strategy enhanced with stakeholder engagement and complexity science. Drawing on tenets of ethnographic research, we developed a lightly-structured method of guided "periodic reflections" to aid in documenting implementation phenomena over time. Reflections are completed as 30-60 min telephone discussions with implementation team members at monthly or bi-monthly intervals, led by a member of the implementation core. Discussion notes are coded to reflect key domains of interest and emergent themes, and can be analyzed singly or in triangulation with other qualitative and quantitative assessments to inform evaluation and implementation activities.

RESULTS

Thirty structured reflections were completed across the three projects during a 15-month period spanning pre-implementation, implementation, and sustainment activities. Reflections provide detailed, near-real-time information on projects' dynamic implementation context, including characteristics of implementation settings and changes in the local or national environment, adaptations to the intervention and implementation plan, and implementation team sensemaking and learning. Reflections also provide an opportunity for implementation teams to engage in recurring reflection and problem-solving.

CONCLUSIONS

To implement new, complex interventions into dynamic organizations, we must better understand the implementation process as it unfolds in real time. Ethnography is well suited to this task, but few approaches exist to aid in integrating ethnographic insights into implementation research. Periodic reflections show potential as a straightforward and low-burden method for documenting events across the life cycle of an implementation effort. They offer an effective means for capturing information on context, unfolding process and sensemaking, unexpected events, and diverse viewpoints, illustrating their value for use as part of an ethnographically-minded implementation approach.

TRIAL REGISTRATION

The two implementation research studies described in this article have been registered as required: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans (NCT02991534); and Implementation of Tailored Collaborative Care for Women Veterans (NCT02950961).

Knowledge Translation to Optimize Adult Inpatient Glycemic Management With Basal Bolus Insulin Therapy and Improve Patient Outcomes

OBJECTIVES

To develop and evaluate a Basal Bolus Insulin Therapy (BBIT) Knowledge Translation toolkit to address barriers to adoption of established best practice with BBIT in the care of adult inpatients.

METHODS

This study was conducted in 2 phases and focused on the hospitalist provider group across 4 acute care facilities in Calgary. Phase 1 involved a qualitative evaluation of provider and site specific barriers and facilitators, which were mapped to validated interventions using behaviour change theory. This informed the co-development and optimization of the BBIT Knowledge Translation toolkit, with each tool targeting a specific barrier to improved diabetes care practice, including BBIT ordering. In Phase 2, the BBIT Knowledge Translation toolkit was implemented and evaluated, focusing on BBIT ordering frequency, as well as secondary outcomes of hyperglycemia (patient-days with BG >14.0 mmol/L), hypoglycemia (patient-days with BG <4.0 mmol/L), and acute length of stay.

RESULTS

Implementation of the BBIT Knowledge Translation toolkit resulted in a significant 13% absolute increase in BBIT ordering. Hyperglycemic patient-days were significantly reduced, with no increase in hypoglycemia. There was a significant, absolute 14% reduction in length of stay.

CONCLUSIONS

The implementation of an evidence-informed, multifaceted BBIT Knowledge Translation toolkit effectively reduced a deeply entrenched in-patient diabetes care gap. The resulting sustained practice change improved patient clinical and system resource utilization outcomes. This systemic approach to implementation will guide further scale and spread of glycemic optimization initiatives.

Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER): a protocol for a program of research

BACKGROUND

The Enhancing Mental and Physical health of Women through Engagement and Retention or EMPOWER program represents a partnership with the US Department of Veterans Health Administration (VA) Health Service Research and Development investigators and the VA Office of Women's Health, National Center for Disease Prevention and Health Promotion, Primary Care-Mental Health Integration Program Office, Women's Mental Health Services, and the Office of Patient Centered Care and Cultural Transformation. EMPOWER includes three projects designed to improve women Veterans' engagement and retention in evidence-based care for high-priority health conditions, i.e., prediabetes, cardiovascular, and mental health.

METHODS/DESIGN

The three proposed projects will be conducted in VA primary care clinics that serve women Veterans including general primary care and women's health clinics. The first project is a 1-year quality improvement project targeting diabetes prevention. Two multi-site research implementation studies will focus on cardiovascular risk prevention and collaborative care to address women Veterans' mental health treatment needs respectively. All projects will use the evidence-based Replicating Effective Programs (REP) implementation strategy, enhanced with multi-stakeholder engagement and complexity theory. Mixed methods implementation evaluations will focus on investigating primary implementation outcomes of adoption, acceptability, feasibility, and reach. Program-wide organizational-, provider-, and patient-level measures and tools will be utilized to enhance synergy, productivity, and impact. Both implementation research studies will use a non-randomized stepped wedge design.

DISCUSSION

EMPOWER represents a coherent program of women's health implementation research and quality improvement that utilizes cross-project implementation strategies and evaluation methodology. The EMPOWER Quality Enhancement Research Initiative (QUERI) will constitute a major milestone for realizing women Veterans' engagement and empowerment in the VA system. EMPOWER QUERI will be conducted in close partnership with key VA operations partners, such as the VA Office of Women's Health, to disseminate and spread the programs nationally.

TRIAL REGISTRATION

The two implementation research studies described in this protocol have been registered as required: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans: Trial registration NCT02991534 , registered 9 December 2016. Implementation of Tailored Collaborative Care for Women Veterans: Trial registration NCT02950961 , registered 21 October 2016.

O pensamento complexo e suas repercussões na gestão em enfermagem e saúde

Objetivo: evidenciar el conocimiento científico sobre la teoría de la complejidad en las publicaciones científicas sobre gestión en enfermería y salud. Método: revisión integrativa que se realizó en mayo del 2014, en las bases de datos LILACS, BDENF y PubMed por medio de la combinación de las siguientes palabras clave: teoría de la complejidad, pensamiento complejo, Edgar Morin, enfermeros, enfermería, organización, administración, gestión y gerencia. Se incluyeron diez artículos, publicados entre 2004 y 2013. Resultados: se evidenció el crecimiento de la producción científica sobre el pensamiento complejo en la gestión de enfermería y salud. Todos eran artículos originales; siete de abordaje cualitativo. Interpretación: se construyeron dos categorías temáticas: “Pensamiento complejo que sostiene las prácticas de la gerencia del cuidado” y “Administración compleja en la perspectiva de las organizaciones de enfermería y salud”. Conclusiones: el pensamiento complejo es un paradigma relacionado a la integralidad, multidisciplinariedad, atención a las redes de apoyo y articulación de los saberes. Se ha usado como modelo de gestión en organizaciones vivas e imprevisibles para promover la organización de los sistemas complejos adaptativos. Este estudio contribuye con la aproximación del referencial de la complejidad con los conceptos de gestión en enfermería y salud, dando mayor visibilidad para futuras publicaciones.

Preventing falls in assisted living: Results of a quality improvement pilot study

Residents of assisted living (AL) communities are at high risk for falls, which result in negative outcomes and high health care costs. Adapting effective falls prevention programs for AL quality improvement (QI) has the potential to reduce falls, improve resident quality of life, and reduce costs. This project tested the feasibility and outcomes of an evidence-based multi-component QI program, the Assisted Living Falls Prevention and Monitoring Program (AL-FPMP). Resident posture and gait improved, likely due to exercise and/or physical therapy. Effective falls prevention QI programs can be implemented in AL, and are advised to (1) establish and maintain a falls team to create a culture focused on the reduction of falls risk; (2) teach staff to assess residents using the Morse Falls Scale to increase their awareness of residents' falls risk and improvement; and (3) modify existing exercise programs to address balance and lower body strength.

Reporting on the Strategies Needed to Implement Proven Interventions: An Example From a "Real-World" Cross-Setting Implementation Study

The objective of this study was to empirically demonstrate the use of a new framework for describing the strategies used to implement quality improvement interventions and provide an example that others may follow. Implementation strategies are the specific approaches, methods, structures, and resources used to introduce and encourage uptake of a given intervention's components. Such strategies have not been regularly reported in descriptions of interventions' effectiveness, or in assessments of how proven interventions are implemented in new settings. This lack of reporting may hinder efforts to successfully translate effective interventions into "real-world" practice. A recently published framework was designed to standardize reporting on implementation strategies in the implementation science literature. We applied this framework to describe the strategies used to implement a single intervention in its original commercial care setting, and when implemented in community health centers from September 2010 through May 2015. Per this framework, the target (clinic staff) and outcome (prescribing rates) remained the same across settings; the actor, action, temporality, and dose were adapted to fit local context. The framework proved helpful in articulating which of the implementation strategies were kept constant and which were tailored to fit diverse settings, and simplified our reporting of their effects. Researchers should consider consistently reporting this information, which could be crucial to the success or failure of implementing proven interventions effectively across diverse care settings.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02299791.

Moving knowledge about family violence into public health policy and practice: a mixed method study of a deliberative dialogue

BACKGROUND

There is a need to understand scientific evidence in light of the context within which it will be used. Deliberative dialogues are a promising strategy that can be used to meet this evidence interpretation challenge.

METHODS

We evaluated a deliberative dialogue held by a transnational violence prevention network. The deliberative dialogue included researchers and knowledge user partners of the Preventing Violence Across the Lifespan (PreVAiL) Research Network and was incorporated into a biennial full-team meeting. The dialogue included pre- and post-meeting activities, as well as deliberations embedded within the meeting agenda. The deliberations included a preparatory plenary session, small group sessions and a synthesizing plenary. The challenge addressed through the process was how to mobilize research to orient health and social service systems to prevent family violence and its consequences. The deliberations focused on the challenge, potential solutions for addressing it and implementation factors. Using a mixed-methods approach, data were collected via questionnaires, meeting minutes, dialogue documents and follow-up telephone interviews.

RESULTS

Forty-four individuals (all known to each other and from diverse professional roles, settings and countries) participated in the deliberative dialogue. Ten of the 12 features of the deliberative dialogue were rated favourably by all respondents. The mean behavioural intention score was 5.7 on a scale from 1 (strongly disagree) to 7 (strongly agree), suggesting that many participants intended to use what they learned in their future decision-making. Interviews provided further insight into what might be done to facilitate the use of research in the violence prevention arena.

CONCLUSION

Findings suggest that participants will use dialogue learnings to influence practice and policy change. Deliberative dialogues may be a viable strategy for collaborative sensemaking of research related to family violence prevention, and other public health topics.

A workplace health promotion application of the Precede-Proceed model in a regional and remote mining company in Whyalla, South Australia

Purpose

– Workplace health promotion enables the dissemination of health-related information to a large portion of society and provides a vehicle for translating results of efficacy studies to effective lifestyle interventions under less controlled real-world conditions. To achieve effectiveness there needs to be a systematic approach to the design, implementation, and evaluation of workplace health promotion interventions. The purpose of this paper is to describe the development of a workplace programme in a mining and steel making town in regional South Australia.

Design/methodology/approach

– The Precede-Proceed model (PPM) was used as a framework to design the development, implementation, and evaluation of the programme.

Findings

– Quality of life issues and antecedents of modifiable behavioural and environmental factors to be targeted by interventions were identified. Relevant socio-behavioural theories were used to guide intervention development and evaluation. An intervention programme was planned to enable the delivery of educational and skills-development strategies by peers within structured organisational work units.

Originality/value

– This research utilises the PPM to develop, implement, and evaluate intervention strategies targeting the development of diabetes and cardiometabolic risk in a remotely located workplace population. Novel to this approach is the utilisation of the entire PPM in the research; the multiple baseline, interrupted time series design of the study; and its application in a workplace environment noted for increased health risk factors, within a community at high risk of development of type 2 diabetes.

Trends in guideline implementation: a scoping systematic review

BACKGROUND

There is currently no reliable way to choose strategies that are appropriate for implementing guidelines facing different barriers. This study examined trends in guideline implementation by topic over a 10-year period to explore whether and how strategies may be suitable for addressing differing barriers.

METHODS

A scoping systematic review was performed. MEDLINE and EMBASE were searched from 2004 to 2013 for studies that evaluated the implementation of guidelines on arthritis, diabetes, colorectal cancer and heart failure. Data on study characteristics, reason for implementation (new guideline or quality improvement), implementation strategy used, rationale for selecting that strategy and reported impact were extracted and summarized. Interventions were mapped against a published taxonomy of guideline implementation strategies.

RESULTS

The search resulted in 1,709 articles; 156 were retrieved and 127 were excluded largely because they did not evaluate guideline implementation, leaving 32 eligible for review (4 arthritis, 3 colorectal cancer, 21 diabetes, 4 heart failure). Six of 7 randomized trials and 8 of 25 observational studies had a low risk of bias. Most studies promoted guideline use for quality improvement (78.0%). Few studies rationalized strategy choice (18.8%). Most employed multiple approaches and strategies, most often educational meetings and print material for professionals or patients. Few studies employed organizational, financial or regulatory approaches. Strategies employed that were unique to the published taxonomy included professional (print material, tailoring guidelines, self-audit training or material) and patient strategies (education, counselling, group interaction, print material, reminders). Most studies achieved positive impact (87.5%). This did not appear to be associated with guideline topic, use of theory or barrier assessment, or number or type of implementation approaches and strategies.

CONCLUSIONS

While few studies were eligible, limiting insight on how to choose implementation strategies that address guideline-specific barriers, this review identified other important findings. Education for professionals or patients and print material were the most commonly employed strategies for translating guidelines to practice. Mapping of strategies onto the published taxonomy identified gaps in guideline implementation that represent opportunities for future research and expanded the taxonomy.

Developing a checklist for guideline implementation planning: review and synthesis of guideline development and implementation advice

Background

Developers, users and others have requested or advocated for guidance on how to plan for, and implement guidelines concurrent to their development given that existing resources are lacking such information. The purpose of this research was to develop a guideline implementation planning checklist.

Methods

Documents that described or evaluated the processes of planning or undertaking implementation were identified in several publications that had systematically identified such resources, and by searching medical literature databases (MEDLINE, EMBASE). Data that described implementation planning; how to develop guideline versions or tools that would support user implementation; and options and mechanisms for disseminating or implementing guidelines were independently extracted from eligible documents by the principal investigator and a trained research assistant. Data were integrated to create a unique list of guideline implementation planning processes and considerations.

Results

Thirty-five documents were eligible. Of these, 16 (45.7%) provided sparse information on implementation planning, 25 (71.4%) mentioned different versions or tools for implementation, and 30 (85.7%) listed options for dissemination or implementation. None provided instructions for operationalizing implementation strategies. Data were integrated into a multi-item Guideline Implementation Planning Checklist including considerations for implementation planning (12), development of implementation tools (8), types of implementation tools (12), and options for dissemination (11) and implementation (12).

Conclusions

Developers or users can apply the Guideline Implementation Planning Checklist to prepare for and/or undertake guideline implementation. Further development of the checklist is warranted to elaborate on all components. In ongoing research, we will consult with the international guideline community to do so. At the same time, guideline implementation is complex, so developers and users would benefit from training, and by including knowledge translation experts and brokers on implementation planning committees.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0205-5) contains supplementary material, which is available to authorized users.

Manifestations and implications of uncertainty for improving healthcare systems: an analysis of observational and interventional studies grounded in complexity science

Background

The application of complexity science to understanding healthcare system improvement highlights the need to consider interdependencies within the system. One important aspect of the interdependencies in healthcare delivery systems is how individuals relate to each other. However, results from our observational and interventional studies focusing on relationships to understand and improve outcomes in a variety of healthcare settings have been inconsistent. We sought to better understand and explain these inconsistencies by analyzing our findings across studies and building new theory.

Methods

We analyzed eight observational and interventional studies in which our author team was involved as the basis of our analysis, using a set theoretical qualitative comparative analytic approach. Over 16 investigative meetings spanning 11 months, we iteratively analyzed our studies, identifying patterns of characteristics that could explain our set of results.

Our initial focus on differences in setting did not explain our mixed results. We then turned to differences in patient care activities and tasks being studied and the attributes of the disease being treated. Finally, we examined the interdependence between task and disease.

Results

We identified system-level uncertainty as a defining characteristic of complex systems through which we interpreted our results. We identified several characteristics of healthcare tasks and diseases that impact the ways uncertainty is manifest across diverse care delivery activities. These include disease-related uncertainty (pace of evolution of disease and patient control over outcomes) and task-related uncertainty (standardized versus customized, routine versus non-routine, and interdependencies required for task completion).

Conclusions

Uncertainty is an important aspect of clinical systems that must be considered in designing approaches to improve healthcare system function. The uncertainty inherent in tasks and diseases, and how they come together in specific clinical settings, will influence the type of improvement strategies that are most likely to be successful. Process-based efforts appear best-suited for low-uncertainty contexts, while relationship-based approaches may be most effective for high-uncertainty situations.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0165-1) contains supplementary material, which is available to authorized users.

Mapping barriers and intervention activities to behaviour change theory for Mobilization of Vulnerable Elders in Ontario (MOVE ON), a multi-site implementation intervention in acute care hospitals

BACKGROUND

As evidence-informed implementation interventions spread, they need to be tailored to address the unique needs of each setting, and this process should be well documented to facilitate replication. To facilitate the spread of the Mobilization of Vulnerable Elders in Ontario (MOVE ON) intervention, the aim of the current study is to develop a mapping guide that links identified barriers and intervention activities to behaviour change theory.

METHODS

Focus groups were conducted with front line health-care professionals to identify perceived barriers to implementation of an early mobilization intervention targeted to hospitalized older adults. Participating units then used or adapted intervention activities from an existing menu or developed new activities to facilitate early mobilization. A thematic analysis was performed on the focus group data, emphasizing concepts related to barriers to behaviour change. A behaviour change theory, the 'capability, opportunity, motivation-behaviour (COM-B) system', was used as a taxonomy to map the identified barriers to their root causes. We also mapped the behaviour constructs and intervention activities to overcome these.

RESULTS

A total of 46 focus groups were conducted across 26 hospital inpatient units in Ontario, Canada, with 261 participants. The barriers were conceptualized at three levels: health-care provider (HCP), patient, and unit. Commonly mentioned barriers were time constraints and workload (HCP), patient clinical acuity and their perceived 'sick role' (patient), and lack of proper equipment and human resources (unit level). Thirty intervention activities to facilitate early mobilization of older adults were implemented across hospitals; examples of unit-developed intervention activities include the 'mobility clock' communication tool and the use of staff champions. A mapping guide was created with barriers and intervention activities matched though the lens of the COM-B system.

CONCLUSIONS

We used a systematic approach to develop a guide, which maps barriers, intervention activities, and behaviour change constructs in order to tailor an implementation intervention to the local context. This approach allows implementers to identify potential strategies to overcome local-level barriers and to document adaptations.

Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: a qualitative study

Objectives

The surgical safety checklist (SSC) is meant to enhance patient safety but studies of its impact conflict. This study explored factors that influenced SSC adherence to suggest how its impact could be optimized.

Methods

Participants were recruited purposively by profession, region, hospital type and time using the SSC. They were asked to describe how the SSC was adopted, associated challenges, perceived impact, and suggestions for improving its use. Grounded theory and thematic analysis were used to collect and analyse data. Findings were interpreted using an implementation fidelity conceptual framework.

Results

Fifty-one participants were interviewed (29 nurses, 13 surgeons, 9 anaesthetists; 18 small, 14 large and 19 teaching hospitals; 8 regions; 31 had used the SC for ≤12 months, 20 for 13+ months). The SSC was inconsistently reviewed, and often inaccurately documented as complete. Adherence was influenced by multiple issues. Extensive modification to accommodate existing practice patterns eliminated essential interaction at key time points to discuss patient management. Staff were often absent or not paying attention. They did not feel it was relevant to their work given limited evidence of its effectiveness, and because they were not engaged in its implementation. Organizations provided little support for implementation, training, monitoring and feedback, which are needed to overcome these, and other individual and team factors that challenged SSC adherence. Responses were similar across participants with different characteristics.

Conclusions

Multiple processes and factors influenced SSC adherence. This may explain why, in studies evaluating SSC impact, outcomes were variable. Recommendations included continuing education, time for pilot-testing, and engaging all staff in SSC review. Others may use the implementation fidelity framework to plan SSC implementation or evaluate SSC adherence. Further research is needed to establish which SSC components can be modified without compromising its effectiveness.

Applying complexity theory: a review to inform evaluation design

Complexity theory has increasingly been discussed and applied within evaluation literature over the past decade. This article reviews the discussion and use of complexity theory within academic journal literature. The aim is to identify the issues to be considered when applying complexity theory to evaluation. Reviewing 46 articles, two groups of themes are identified. The first group considers implications of applying complexity theory concepts for defining evaluation purpose, scope and units of analysis. The second group of themes consider methodology and method. Results provide a starting point for a configuration of an evaluation approach consistent with complexity theory, whilst also identifying a number of design considerations to be resolved within evaluation planning.

Participation in decision making as a property of complex adaptive systems: developing and testing a measure

Objectives. To (1) describe participation in decision-making as a systems-level property of complex adaptive systems and (2) present empirical evidence of reliability and validity of a corresponding measure. Method. Study 1 was a mail survey of a single respondent (administrators or directors of nursing) in each of 197 nursing homes. Study 2 was a field study using random, proportionally stratified sampling procedure that included 195 organizations with 3,968 respondents. Analysis. In Study 1, we analyzed the data to reduce the number of scale items and establish initial reliability and validity. In Study 2, we strengthened the psychometric test using a large sample. Results. Results demonstrated validity and reliability of the participation in decision-making instrument (PDMI) while measuring participation of workers in two distinct job categories (RNs and CNAs). We established reliability at the organizational level aggregated items scores. We established validity of the multidimensional properties using convergent and discriminant validity and confirmatory factor analysis. Conclusions. Participation in decision making, when modeled as a systems-level property of organization, has multiple dimensions and is more complex than is being traditionally measured. Managers can use this model to form decision teams that maximize the depth and breadth of expertise needed and to foster connection among them.

Study protocol: translating and implementing psychosocial interventions in aged home care the lifestyle engagement activity program (LEAP) for life

BACKGROUND

Tailored psychosocial activity-based interventions have been shown to improve mood, behaviour and quality of life for nursing home residents. Occupational therapist delivered activity programs have shown benefits when delivered in home care settings for people with dementia. The primary aim of this study is to evaluate the effect of LEAP (Lifestyle Engagement Activity Program) for Life, a training and practice change program on the engagement of home care clients by care workers. Secondary aims are to evaluate the impact of the program on changes in client mood and behaviour.

METHODS/DESIGN

The 12 month LEAP program has three components: 1) engaging site management and care staff in the program; 2) employing a LEAP champion one day a week to support program activities; 3) delivering an evidence-based training program to care staff. Specifically, case managers will be trained and supported to set meaningful social or recreational goals with clients and incorporate these into care plans. Care workers will be trained in and encouraged to practise good communication, promote client independence and choice, and tailor meaningful activities using Montessori principles, reminiscence, music, physical activity and play. LEAP Champions will be given information about theories of organisational change and trained in interpersonal skills required for their role. LEAP will be evaluated in five home care sites including two that service ethnic minority groups. A quasi experimental design will be used with evaluation data collected four times: 6-months prior to program commencement; at the start of the program; and then after 6 and 12 months. Mixed effect models will enable comparison of change in outcomes for the periods before and during the program. The primary outcome measure is client engagement. Secondary outcomes for clients are satisfaction with care, dysphoria/depression, loneliness, apathy and agitation; and work satisfaction for care workers. A process evaluation will also be undertaken.

DISCUSSION

LEAP for Life may prove a cost-effective way to improve client engagement and other outcomes in the community setting.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612001064897.