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

Stimulating implementation of clinical practice guidelines in hospital care from a central guideline organization perspective: A systematic review

BACKGROUND

The uptake of guidelines in care is inconsistent. This review focuses on guideline implementation strategies used by guideline organizations (governmental agencies, scientific/professional societies and other umbrella organizations), experienced implementation barriers and facilitators and impact of their implementation efforts.

METHODS

We searched PUBMED, EMBASE and CINAHL and conducted snowballing. Eligibility criteria included guidelines focused on hospital care and OECD countries. Study quality was assessed using the Mixed Methods Appraisal Tool. We used framework analysis, narrative synthesis and summary statistics.

RESULTS

Twenty-six articles were included. Sixty-two implementation strategies were reported, used in different combinations and ranged between 1 and 16 strategies per initiative. Most frequently reported strategies were educational session(s) and implementation supporting materials. The most commonly reported barrier and facilitator were respectively insufficient healthcare professionals' time and resources; and guideline's credibility, evidence base and relevance. Eighty-five percent of initiatives that measured impact achieved improvements in adoption, knowledge, behavior and/or clinical outcomes. No clear optimal approach for improving guideline uptake and impact was found. However, we found indications that employing multiple active implementation strategies and involving external organizations and hospital staff were associated with improvements.

CONCLUSION

Guideline organizations employ diverse implementation strategies and encounter multiple barriers and facilitators. Our study uncovered potential effective implementation practices. However, further research is needed on effective tailoring of implementation approaches to increase uptake and impact of guidelines.

Mobilizing strategic inflection points for sustainment of an effective intervention in an integrated learning health system: an interpretive description

BACKGROUND

Innovative models of care have the potential to improve the sustainability of health systems by improving patient and provider experiences and population outcomes while simultaneously reducing costs. Yet, it is challenging to recognize the distinctive points during research and quality improvement processes that contribute to sustainment of effective interventions. The business concept of an inflection point-the position on the curve of a trajectory where the progress in implementation of an intervention is accelerated or decelerated-may be useful to understand implementation and improve sustainability and ultimately sustainment of effective interventions. The purpose of this study was to retrospectively identify and describe strategic inflection points that accelerated the sustainability process and led to the sustainment of Alberta Family Integrated Care.

METHODS

This qualitative study was conducted in Alberta, Canada and employed an interpretive description design. Purposively sampled documents (proposals, project management plans, reports to funders and sponsors, meeting minutes, and fidelity audit and feedback checklists) from the Alberta Family Integrated Care cluster randomized controlled trial and quality improvement project constituted data for this study.

RESULTS

To accelerate sustainability in the research context, we identified (1) alignment with strategic priorities, (2) iterative, user-centered co-design, and (3) contextualization of implementation as strategic inflection points. To accelerate sustainability in the health system context, we identified (1) the learning health system, (2) enduring partnerships, (3) responsivity to societal and system change, (4) embedded governance, and (5) intentional integration into the health system as strategic inflection points. Capitalizing on these strategic inflection points led to sustainment of Alberta Family Integrated Care in the provincial health system.

CONCLUSIONS

We identified key inflection points in the research and health system contexts that led to sustainment of Alberta Family Integrated Care. By anticipating, recognizing, and leveraging inflection points in the sustainability process, researchers may be able to accelerate implementation and achieve sustainment of multi-component interventions in complex systems.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02879799. Registration date: May 27, 2016. Protocol version: June 9, 2016; version 2. Protocol publication: https://doi.org/10.1186/s13063-017-2181-3 .

Managers' perspectives on their role in implementing fall prevention interventions: a qualitative interview study in Norwegian homecare services

Introduction

The implementation of fall prevention interventions in homecare services is crucial for reducing falls among older adults and effective leadership could determine success. Norwegian homecare services provide home nursing, rehabilitation, and practical assistance, to residents living in private homes or assisted living facilities. This study aims to explore how managers in Norwegian homecare services experience implementation of fall prevention interventions and how they perceive their roles.

Methods

We conducted 14 semi-structured individual interviews with managers from different levels of homecare services in five city districts. The interviews were transcribed verbatim and reflexive thematic analysis was used to analyze the material.

Results

The analysis resulted in three main themes: (1) understanding organizational mechanisms to facilitate new practices, (2) practicing positive leadership behavior to facilitate implementation, and (3) demonstrating persistence to sustain implementation. Our results showed the importance of clear leadership across all levels of the organization and the value of devoting time and utilizing existing systems. Managers described using recognition and positive attitudes to motivate employees in the implementation process. They emphasized listening to and involving employees, providing trust, and being flexible. However, the implementation process could be challenging, highlighting the need for managers to be persistent.

Conclusion

Managers at all levels play an important role in the implementation of fall prevention, but there is a need to define and align their specific roles in the process. Understanding how to use existing systems and influence through positive leadership behavior seem to be vital for success. Recognizing the demanding nature of implementation, managers emphasized the importance of systems for long term support. The study findings may influence how managers in clinical practice engage in the implementation process and inform future researchers about managers' roles in implementation in homecare services.

Journey toward Baby-Friendly Hospital Initiative designation: Healthcare professional's view on successful implementation process and maintenance of accreditation

PROBLEM

The Baby-Friendly Hospital Initiative has yet to achieve widespread global implementation.

BACKGROUND

The implementation of the Baby-Friendly Hospital Initiative has been recognised as complex. The challenge has been to maintain accreditation.

AIM

To explore and gain a deeper understanding of the healthcare professionals' perceptions of the implementation process and the maintenance of the Baby-Friendly Hospital Initiative.

METHODS

A qualitative descriptive study with focus groups (n = 10) of the nurses, midwives and unit leaders (n = 43) perceptions of the implementation process were analysed using inductive thematic analysis.

FINDINGS

Analysis of the data revealed five main themes: groundwork for the baby-focused breastfeeding context, management support throughout the process, promoting baby-friendly practices, effective communication ensuring the right track, and supporting the maintenance of BFHI designation. The main themes describe the implementation as a journey of climbing a hill and after reaching the top trying to maintain their position.

DISCUSSION

The starting point for implementation was an optimal environment supporting baby-friendly breastfeeding practices. The support of the management of the organisation was an important way of moving the implementation forward. Commitment to the common goal strengthened the baby-friendly approach and with concrete and immediate feedback the right pathway on a journey was ensured.

CONCLUSION

Practical ways to support the implementation journey include regular update education on breastfeeding and continuous monitoring, as well as providing statistics to health professionals. Global guidelines on how to sustain change are needed. This will ensure that the work done is not wasted.

First-line managers' experience of guideline implementation in orthopaedic nursing and rehabilitation: a qualitative study

BACKGROUND

First-line managers have a unique role and potential in encouraging the use of evidence-based clinical practice guidelines (CPGs) and thus serve the provision of safe patient care. In acute and planned hospital care, effective yet safeguarded nursing procedures are a necessity. Little is currently known about how first-line managers engage in supporting the adoption of evidence-based nursing care and about what barriers and enablers there are for implementation of CPGs in the orthopaedic care context.

PURPOSE

To investigate first-line managers' experience of clinical practice guideline implementation in orthopaedic care.

METHODS

This qualitative interview study included 30 first-line nursing and rehabilitation managers in 17 orthopaedic units in Sweden. A deductive content analysis, with the Ottawa Model of Implementation Leadership as a guide, was employed.

RESULTS

To the first-line managers, any guideline implementation required them to balance contexts, including their outer context (signified by the upper-level management and decision-makers) and their inner context, including staff and patients in their unit(s). Acting in response to these contexts, the managers described navigating the organization and its terms and conditions; using relations-, change-, and task-oriented leadership, such as involving the staff; motivating the change by emphasizing the patient benefits; and procuring resources, such as time and training. Even though they knew from past experience what worked when implementing CPGs, the first-line managers often encountered barriers within the contexts that hampered successful implementation.

CONCLUSIONS

Although first-line managers know how to effectively implement CPGs, an organization's terms and conditions can limit their opportunities to fully do so. Organizational awareness of what supports and hinders first-line managers to offer implementation leadership can enhance opportunities to alter behaviours and conditions for the benefit of CPG implementation.

TRIAL REGISTRATION

The study was registered as NCT04700969 with the U.S. National Institutes of Health Clinical Trials Registry on 8 January 2021.

"Nothing Is More Powerful than Words:" How Patient Experience Narratives Enable Improvement

BACKGROUND AND OBJECTIVES

Patient experience narratives (narratives) are an increasingly important element of both measurement approaches and improvement efforts in healthcare. Prior studies show that narratives are considered by both clinicians and staff to be an appealing, meaningful, and credible form of evidence on performance. They also suggest that making concrete use of narratives within organizational settings to improve care can be complex and challenging. Our qualitative study was designed to explore how middle managers working in a health system's outpatient clinics value and use written narratives in their day-to-day work.

METHODS

We conducted qualitative interviews with 20 middle managers working in 8 outpatient clinics. Interviews were fully transcribed, loaded into MAX-QDA software, and coded using thematic analysis techniques. Code reports were extracted and reanalyzed for subthemes related to the objectives of this paper.

RESULTS

Middle managers across sites described valuing narratives as a tool to: enable better patient experience assessment by augmenting data from patient experience scores; deepen understanding of and relationships with patients; provide insight about operational issues; identify areas for needed improvement and potential solutions; and facilitate strategic work. They reported using narratives for a range of activities related to their roles as supervisors, such as focusing attention on positive practices and needed improvements, promoting deeper group learning, motivating change, reinforcing sense of purpose for staff, recognizing staff strengths and training needs, and inspiring transformational thinking. Finally, interviewees reported numerous specific quality improvement projects (both short- and longer-term) that were informed by narratives-for example, by identifying an issue to be addressed or by suggesting a workable solution. Together, these interviews suggest a collective "narrative about narratives" woven by these organizational actors-a story which illustrates how narratives are highly relevant for how middle managers derive meaning from their work, put organizational values such as responsive service provision into practice, and enact their roles as supervisors.

CONCLUSIONS

Our results add to the nascent literature a detailed description of how narratives can be used both as a tool for middle managers in their leadership and supervisory roles, and as a blueprint for improvement work within outpatient settings. They also illuminate why patient experience scores may improve when narrative data are collected and used. Finally, our results suggest that for middle managers, perhaps "nothing is more powerful than words" because narratives function as both an insight provider and a compelling tool that adds direction and meaning to workplace endeavors.

Enhancing safety culture in radiology: Key practices and recommendations for sustainable excellence

OBJECTIVES

This review aims to explore and thematically synthesize the existing literature on safety culture within the context of radiology. The primary objective is to identify key practices that effectively strengthen safety culture, highlighting the pivotal roles of leadership, effective teamwork, and interprofessional collaboration in these efforts. The review intends to showcase actionable recommendations that are particularly relevant to the radiology setting.

KEY FINDINGS

The study highlights that effective leadership is fundamental in establishing and nurturing a safety-first approach within radiology departments. Key practices for promoting a safety culture include safety huddles, leadership walkarounds, quality learning boards, intentional patient rounding (frequent patient-care provider interactions), morbidity and mortality meetings, and multidisciplinary team rounds. These practices have been found to facilitate open communication and transparency, which are crucial elements in creating a sustainable safety culture. Additionally, the study underscores the significant role of radiology managers in driving these safety initiatives and acting as facilitators for a culture of safety, focused on long-term excellence and continuous improvement.

CONCLUSION

The study concludes that a multifaceted and comprehensive approach is vital for fostering a safety culture in radiology departments, with a focus on sustainable excellence in patient care. The leadership role is critical in this process, with radiology managers being instrumental in implementing and maintaining effective safety practices.

IMPLICATIONS FOR PRACTICE

This study provides best practices for sustainable safety culture in radiology departments. It advocates for healthcare managers to adopt and integrate these identified practices into their operational strategies. Continuous professional development, focusing on safety and quality in patient care, and fostering a collaborative environment for open discussion and learning from safety incidents are essential for the continued advancement and excellence of healthcare services.

Development of a training program prototype to enhance implementation leadership competencies and behaviours of Chinese unit nurse managers: a qualitative descriptive study

BACKGROUND

Unit nurse managers hold essential positions that can facilitate implementation of evidence-based practice. Studies showed that nurse managers in China lacked competencies and behaviours necessary to lead evidence-based practice implementation. The aim of the current study was to develop a context-fit training program prototype to enhance leadership competencies and behaviours regarding evidence-based practice implementation of Chinese unit nurse managers.

METHOD

We used a descriptive qualitative study design and followed the integrated knowledge translation approach to co-develop the prototype in a tertiary hospital in Changsha, China. Seven nurse managers from the participated hospital and a researcher co-developed the prototype based on the Ottawa Model of Implementation Leadership (O-MILe). The development process encompassed four phases from November 2021 to March 2022 that involved group discussions (n = 4) and individual interviews (n = 21). All data were analysed by two independent researchers using the thematic analysis method.

RESULTS

Managers agreed that all O-MILe behaviours were important to evidence-based practice implementation, and only minor modifications were needed for clarification and adaptation. The actions managers identified that could operationalize the leadership behaviours were related to current clinical practices, evidence-based practice, nurses, patients, interprofessional staff members, incentives and resources, organization and external entities. Three types of general competencies related to evidence-based practice, professional nursing, and implementation leadership were identified. Multimodal activities such as lectures, experience sharing, group discussions, plan development and coaching were suggested to deliver the training program.

CONCLUSIONS

All O-MILe leadership behaviours were perceived as essential for unit nurse managers to lead EBP implementation in the hospital context in China. We identified the leadership actions and the competencies required for nursing managers to implement EBP in China. Further studies are required to evaluate the acceptability and impact of this prototype. Further studies with large sample sizes across various clinical settings are needed to facilitate the generalization of the findings and gain an in-depth understanding of the program.

Ready or Not: A Conceptual Model of Organizational Readiness for Embedded Pragmatic Dementia Research

The National Institute on Aging Alzheimer's Disease/Alzheimer's Disease and Related Dementias Research Implementation Milestones emphasize the need for implementation research that maximizes up-take and scale-up of evidence-based dementia care practices across settings, diverse populations, and disease trajectories. Organizational readiness for implementation is a salient consideration when planning and conducting embedded pragmatic trials, in which interventions are implemented by provider staff. The current article examines the conceptual and theoretical underpinnings of organizational readiness for implementation and the operationalization of this construct. We offer a preliminary conceptual model for explicating and measuring organizational readiness and describe the unique characteristics and demands of implementing evidence-based interventions targeting persons with dementia and/or their care partners. [Research in Gerontological Nursing, 17(3), 149-160.].

Managers' Micro-Communities Matter: The Impact of Clinical Supervision Team on Therapist Perception of the Organization

Positive organizational climate - employee perceptions of their work environment and the impact of this environment on well-being and functioning - is associated with desirable organizational and client-level outcomes in mental health organizations. Clinical supervisors are well-positioned to impact organizational climate, as they serve as intermediaries between higher-level administrators who drive the policies and procedures and the therapists impacted by such decisions. This cross-sectional study examined the role of clinical supervisors as drivers of therapist perceptions of organizational climate within supervisory teams. Specifically, the present study investigated: (1) shared perceptions of organizational climate among therapists on the same supervisory team; (2) predictors of therapist climate perceptions. Eighty-six therapists were supervised by 22 supervisors. Indices of interrater agreement and interrater reliability of therapists on the same supervisory team were examined to determine shared or distinct perceptions of organizational climate. Multi-level models were used to examine whether supervisor attitudes towards evidence-based practices and therapist perceptions of supervisor communication predicted perceived organizational climate. Results showed perceptions of organizational cohesion and autonomy were shared among therapists on the same supervisory team and distinct from therapists on different supervisory teams. Therapist perceptions of their supervisor's communication was positively associated with perceptions of organizational cohesion and autonomy. These findings align with emerging evidence that middle managers shape their employees' experience of their work environment through communication strategies. These findings also point to the potential for intervening at lower organizational levels to improve overall organizational climate.

Leading Quality and Safety on the Frontline - A Case Study of Department Leaders in Nursing Homes

Purpose

The role of healthcare leaders is becoming increasingly complex, and carries great responsibility for patients, employees, and the quality of service delivery. This study explored the barriers and enablers that department leaders in nursing homes encounter when managing the dual responsibilities in Health, Safety and Environment (HSE) and Quality and Patient Safety (QPS).

Methodology

Case study design with data collected through semi structured interviews with 16 department leaders in five Norwegian municipalities. We analyzed the data using qualitative content analysis.

Results

Data analysis resulted in four themes explaining what department leaders in nursing homes experience as barriers and enablers when handling the dual responsibility of HSE and QPS: Temporal capacity: The importance of having enough time to create a health-promoting work environment that ensures patient safety. Relational capacity: Relationships have an impact on work process and outcomes. Professional competence: Competence affects patient safety and leadership strategies. Organizational structure: Organizational frameworks influence how the dual responsibilities are handled.

Conclusion

Evidence from this study showed that external contextual factors (eg, legislations and finances) and internal factors (eg, relationships and expectations) are experienced as barriers and enablers when department leaders are enacting the dual responsibility of HSE and QPS. Of these, relationships were found to be the most significant contributor.

Assessing an innovative method to promote learning from patient narratives: Findings from a field experiment in ambulatory care

OBJECTIVE

To assess whether an online interactive report designed to facilitate interpretation of patients' narrative feedback produces change in ambulatory staff learning, behavior at the individual staff and practice level, and patient experience survey scores.

DATA SOURCES AND SETTING

We studied 22 ambulatory practice sites within an academic medical center using three primary data sources: 333 staff surveys; 20 in-depth interviews with practice leaders and staff; and 9551 modified CG-CAHPS patient experience surveys augmented by open-ended narrative elicitation questions.

STUDY DESIGN

We conducted a cluster quasi-experimental study, comparing 12 intervention and 10 control sites. At control sites, narratives were delivered free-form to site administrators via email; at intervention sites, narratives were delivered online with interactive tools for interpretation, accompanied by user training. We assessed control-versus-intervention site differences in learning, behavior, and patient experience scores.

DATA COLLECTION

Staff surveys and interviews were completed at intervention and control sites, 9 months after intervention launch. Patient surveys were collected beginning 4 months pre-launch through 9 months post-launch. We used control-versus-intervention and difference-in-difference analyses for survey data and thematic analysis for interview data.

PRINCIPAL FINDINGS

Interviews suggested that the interface facilitated narrative interpretation and use for improvement. Staff survey analyses indicated enhanced learning from narratives at intervention sites (29% over control sites' mean of 3.19 out of 5 across eight domains, p < 0.001) and greater behavior change at staff and practice levels (31% and 21% over control sites' means of 3.35 and 3.39, p < 0.001, respectively). Patient experience scores for interactions with office staff and wait time information increased significantly at intervention sites, compared to control sites (3.7% and 8.2%, respectively); however, provider listening scores declined 3.3%.

CONCLUSIONS

Patient narratives presented through structured feedback reporting methods can catalyze positive changes in staff learning, promote behavior change, and increase patient experience scores in domains of non-clinical interaction.

Improving measurement-based care implementation in youth mental health through organizational leadership and climate: a mechanistic analysis within a randomized trial

BACKGROUND

Theory and correlational research indicate organizational leadership and climate are important for successful implementation of evidence-based practices (EBPs) in healthcare settings; however, experimental evidence is lacking. We addressed this gap using data from the WISDOM (Working to Implement and Sustain Digital Outcome Measures) hybrid type III effectiveness-implementation trial. Primary outcomes from WISDOM indicated the Leadership and Organizational Change for Implementation (LOCI) strategy improved fidelity to measurement-based care (MBC) in youth mental health services. In this study, we tested LOCI's hypothesized mechanisms of change, namely: (1) LOCI will improve implementation and transformational leadership, which in turn will (2) mediate LOCI's effect on implementation climate, which in turn will (3) mediate LOCI's effect on MBC fidelity.

METHODS

Twenty-one outpatient mental health clinics serving youth were randomly assigned to LOCI plus MBC training and technical assistance or MBC training and technical assistance only. Clinicians rated their leaders' implementation leadership, transformational leadership, and clinic implementation climate for MBC at five time points (baseline, 4-, 8-, 12-, and 18-months post-baseline). MBC fidelity was assessed using electronic metadata for youth outpatients who initiated treatment in the 12 months following MBC training. Hypotheses were tested using longitudinal mixed-effects models and multilevel mediation analyses.

RESULTS

LOCI significantly improved implementation leadership and implementation climate from baseline to follow-up at 4-, 8-, 12-, and 18-month post-baseline (all ps < .01), producing large effects (range of ds = 0.76 to 1.34). LOCI's effects on transformational leadership were small at 4 months (d = 0.31, p = .019) and nonsignificant thereafter (ps > .05). LOCI's improvement of clinic implementation climate from baseline to 12 months was mediated by improvement in implementation leadership from baseline to 4 months (proportion mediated [pm] = 0.82, p = .004). Transformational leadership did not mediate LOCI's effect on implementation climate (p = 0.136). Improvement in clinic implementation climate from baseline to 12 months mediated LOCI's effect on MBC fidelity during the same period (pm = 0.71, p = .045).

CONCLUSIONS

LOCI improved MBC fidelity in youth mental health services by improving clinic implementation climate, which was itself improved by increased implementation leadership. Fidelity to EBPs in healthcare settings can be improved by developing organizational leaders and strong implementation climates.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04096274. Registered September 18, 2019.

Mid-level managers' perspectives on implementing isoniazid preventive therapy for people living with HIV in Ugandan health districts: a qualitative study

BACKGROUND

Isoniazid preventive therapy (IPT) works to prevent tuberculosis (TB) among people living with HIV (PLHIV), but uptake remains low in Sub-Saharan Africa. In this analysis, we sought to identify barriers mid-level managers face in scaling IPT in Uganda and the mechanisms by which the SEARCH-IPT trial intervention influenced their abilities to increase IPT uptake.

METHODS

The SEARCH-IPT study was a cluster randomized trial conducted from 2017-2021. The SEARCH-IPT intervention created collaborative groups of district health managers, facilitated by local HIV and TB experts, and provided leadership and management training over 3-years to increase IPT uptake in Uganda. In this qualitative study we analyzed transcripts of annual Focus Group Discussions and Key Informant Interviews, from a subset of SEARCH-IPT participants from intervention and control groups, and participant observation field notes. We conducted the analysis using inductive and deductive coding (with a priori codes and those derived from analysis) and a framework approach for data synthesis.

RESULTS

When discussing factors that enabled positive outcomes, intervention managers described feeling ownership over interventions, supported by the leadership and management training they received in the SEARCH-IPT study, and the importance of collaboration between districts facilitated by the intervention. In contrast, when discussing factors that impeded their ability to make changes, intervention and control managers described external funders setting agendas, lack of collaboration in meetings that operated with more of a 'top-down' approach, inadequate supplies and staffing, and lack of motivation among frontline providers. Intervention group managers mentioned redistribution of available stock within districts as well as between districts, reflecting efforts of the SEARCH-IPT intervention to promote between-district collaboration, whereas control group managers mentioned redistribution within their districts to maximize the use of available IPT stock.

CONCLUSIONS

In Uganda, mid-level managers' perceptions of barriers to scaling IPT included limited power to set agendas and control over funding, inadequate resources, lack of motivation of frontline providers, and lack of political prioritization. We found that the SEARCH-IPT intervention supported managers to design and implement strategies to improve IPT uptake and collaborate between districts. This may have contributed to the overall intervention effect in increasing the uptake of IPT among PLHIV compared to standard practice.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03315962 , Registered 20 October 2017.

Exploring expectations and readiness for healthy lifestyle promotion in Swedish primary health care: a qualitative analysis of managers, facilitators, and professionals

OBJECTIVE

Prior to a multifaceted implementation strategy for a healthy lifestyle-promoting practice the expectations of primary health care managers, appointed internal facilitators and health care professionals on supporting change was explored.

DESIGN

This study had an explorative qualitative design using data gathered from individual interviews and focus groups. Qualitative content analysis with a deductive category development was applied using the Consolidated Framework for Implementation Research.

SETTING AND PARTICIPANTS

The study was conducted in a primary care setting in central Sweden as a part of the Act in Time research project. Prior to a multifaceted implementation strategy, we held 16 individual interviews with managers and appointed facilitators and five focus groups with 26 health care professionals.

RESULTS

Managers, facilitators, and professionals held similar expectations, where their expressed need for support corresponded to three constructs: Readiness for implementation, Implementation climate, and Engaging. Our findings indicate the need for strong leadership engagement to focus on how the healthy lifestyle-promoting practice can be anchored among the professionals. Managers at all levels should communicate the vision and goals, enable facilitators and professionals to improve their competencies, build inter-professional teams, and jointly plan the new practice.

CONCLUSION

To change to a healthy lifestyle promoting practice professionals request support from their managers, who in turn need support from the middle and top managers. The requested support includes helping to prioritise health promotion and enabling the primary care centres to build competence and take ownership of the implementation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04799860.

Implementing Clinical Guidelines for the Treatment of Psychosis: The Frontline Leaders' Point of View. A Qualitative Study

Background

Despite the large amount of leadership and implementation theories and recommendations, healthcare services continue to struggle with efficiently incorporating new knowledge. The questioning of conventional leadership approaches in healthcare organizations prompted us to investigate how frontline leaders comprehend their own implementation intentions and actions, and how these intentions and actions may impact the implementation of clinical guidelines in mental healthcare in Norway.

Methods

Employing a theory-driven qualitative design, we conducted nine semi-structured interviews with frontline leaders who had recently led implementation of clinical guidelines for the treatment of psychosis in mental health. We employed Systematic Text Condensation, informed by Normalization Process Theory, to structure and analyze the data and used fidelity scales to measure the degree of implementation and distinguish between leaders' levels of success in implementation.

Results

Frontline leaders in units that achieved high success in implementation described their intentions and actions differently, from those with less success. The former group's actions aligned more closely with the constructs of the Normalization Process Theory compared to the latter group when describing their actions. Frontline leaders leading units with a high degree of implementation success describe relation-orientation, trust, and providing adaptive space for staff members to take initiative. In contrast, those leading units with less implementation success describe more control and guidance of co-operators and place more emphasize on information and knowledge.

Conclusion

Differences in how frontline leaders describe their actions and intentions to achieve clinical guideline implementation suggest that the leadership approach of these frontline leaders is an important factor to consider when planning and conducting implementation. To better understand the implementation process, it is important to pay attention to how frontline leaders customize their leadership approaches to the dynamics of complex organizations, and how they interact with their team and superiors.

Exploring Shared Implementation Leadership of Point of Care Nursing Leadership Teams on Inpatient Hospital Units: Protocol for a Collective Case Study

BACKGROUND

Nursing leadership teams at the point of care (POC), consisting of both formal and informal leaders, are regularly called upon to support the implementation of evidence-based practices (EBPs) in hospital units. However, current conceptualizations of effective leadership for successful implementation typically focus on the behaviors of individual leaders in managerial roles. Little is known about how multiple nursing leaders in formal and informal roles share implementation leadership (IL), representing an important knowledge gap.

OBJECTIVE

This study aims to explore shared IL among formal and informal nursing leaders in inpatient hospital units. The central research question is as follows: How is IL shared among members of POC nursing leadership teams on inpatient hospital units? The subquestions are as follows: (1) What IL behaviors are enacted and shared by formal and informal leaders? (2) What social processes enable shared IL by formal and informal leaders? and (3) What factors influence shared IL in nursing leadership teams?

METHODS

We will use a collective case study approach to describe and generate an in-depth understanding of shared IL in nursing. We will select nursing leadership teams on 2 inpatient hospital units that have successfully implemented an EBP as instrumental cases. We will construct data through focus groups and individual interviews with key informants (leaders, unit staff, and senior nurse leaders), review of organizational documents, and researcher-generated field notes. We have developed a conceptual framework of shared IL to guide data analysis, which describes effective IL behaviors, formal and informal nursing leaders' roles at the POC, and social processes generating shared leadership and influencing contextual factors. We will use the Framework Method to systematically generate data matrices from deductive and inductive thematic analysis of each case. We will then generate assertions about shared IL following a cross-case analysis.

RESULTS

The study protocol received research ethics approval (2022-8408) on February 24, 2022. Data collection began in June 2022, and we have recruited 2 inpatient hospital units and 25 participants. Data collection was completed in December 2023, and data analysis is ongoing. We anticipate findings to be published in a peer-reviewed journal by late 2024.

CONCLUSIONS

The anticipated results will shed light on how multiple and diverse members of the POC nursing leadership team enact and share IL. This study addresses calls to advance knowledge in promoting effective implementation of EBPs to ensure high-quality health care delivery by further developing the concept of shared IL in a nursing context. We will identify strategies to strengthen shared IL in nursing leadership teams at the POC, informing future intervention studies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54681.

Managing patient safety and staff safety in nursing homes: exploring how leaders of nursing homes negotiate their dual responsibilities-a case study

Objective

Within healthcare, the role of leader is becoming more complex, and healthcare leaders carry an increasing responsibility for the performance of employees, the experience and safety of patients and the quality of care provision. This study aimed to explore how leaders of nursing homes manage the dual responsibility of both Health, Safety and Environment (HSE) and Quality and Patient Safety (QPS), focusing particularly on the approaches leaders take and the dilemmas they face. In addition, we wanted to examine how leaders experience and manage the challenges of HSE and QPS in a holistic way.

Design/setting

The study was designed as a case study. Data were collected through semi structured individual interviews with leaders of nursing homes in five Norwegian municipalities.

Participants

13 leaders of nursing homes in urban and rural municipalities participated in this study.

Results

Data analysis resulted in four themes explaining how leaders of nursing homes manage the dual responsibility of HSE and QPS, and the approaches they take and the dilemmas they face: 1.Establishing good systems and building a culture for a work environment that promotes health and patient safety.2.Establish channels for internal and external collaboration and communication.3.Establish room for maneuver to exercise leadership.4.Recognizing and having the mandate to handle possible tensions in the dual responsibility of HSE and QPS.

Conclusions

The study showed that leaders of nursing homes who are responsible for ensuring quality and safety for both patients and staff, experience tensions in handling this dual responsibility. They acknowledged the importance of having time to be present as a leader, to have robust systems to maintain HSE and QPS, and that conflicting aspects of legislation are an everyday challenge.

The dilemma of the split between theory and reality as experienced by primary healthcare professionals: a mixed methods study of evidence-based practice in a primary care context

BACKGROUND

Primary care depends upon a good information flow across professional and structural boundaries to provide the best care for patients. Previous research has mainly focused on Evidence-Based Practice (EBP) within specific professions. Mapping of pan-professional experiences of and attitudes to EBP in publicly funded clinical practice is necessary to deepen the understanding of EBP and its implementation. Thus, this study aimed to investigate healthcare professionals' experiences of and attitudes towards working in accordance with EBP in primary care.

METHODS

The study used a convergent mixed methods design divided into two strands: a quantitative enquiry tool (Evidence-Based Practice Attitude Scale, EBPAS) and a set of qualitative interviews analysed by means of qualitative content analysis. Both strands included all primary care employees with patient interaction in the studied county (n = 625), including doctors, nurses, physiotherapists, psychologists and assistant nurses. Out of the original 625 healthcare professionals, 191 finished the first strand and 8 volunteered for the second strand (2 nurses, 2 physiotherapists, 1 psychiatrist and 3 doctors).

RESULTS

The EBPAS value of 2.8 (max 4) indicated a generally positive attitude towards EBP amongst the population, which was also evident in the interviews. However, there were additional experiences of not having the ability or resources to engage in EBP. This was illustrated by the theme that emerged from the qualitative content analysis: "The dilemma of the split between theory and reality". Due to the organisational and managerial focus on efficiency rather than quality of care, there were few or no incentives for promoting individual educational or research development.

CONCLUSIONS

Although the general attitude towards EBP is positive, experiences of practising it differ. There is a need to increase knowledge of EBP concepts, requirements and implementation in the clinical setting. The absence of opportunities to do research and collegial debate about new ways of finding and implementing research-based evidence results might influence the quality of care.

Voice is not enough: A multilevel model of how frontline voice can reach implementation

ISSUE

When frontline employees' voice is not heard and their ideas are not implemented, patient care is negatively impacted, and frontline employees are more likely to experience burnout and less likely to engage in subsequent change efforts.

CRITICAL THEORETICAL ANALYSIS

Theory about what happens to voiced ideas during the critical stage after employees voice and before performance outcomes are measured is nascent. We draw on research from organizational behavior, human resource management, and health care management to develop a multilevel model encompassing practices and processes at the individual, team, managerial, and organizational levels that, together, provide a nuanced picture of how voiced ideas reach implementation.

INSIGHT/ADVANCE

We offer a multilevel understanding of the practices and processes through which voice leads to implementation; illuminate the importance of thinking temporally about voice to better understand the complex dynamics required for voiced ideas to reach implementation; and highlight factors that help ideas reach implementation, including voicers' personal and interpersonal tactics with colleagues and managers, as well as senior leaders modeling and explaining norms and making voice-related processes and practices transparent.

PRACTICE IMPLICATIONS

Our model provides evidence-based strategies for bolstering rejected or ignored ideas, including how voicers (re)articulate ideas, whom they enlist to advance ideas, how they engage peers and managers to improve conditions for intentional experimentation, and how they take advantage of listening structures and other formal mechanisms for voice. Our model also highlights how senior leaders can make change processes and priorities explicit and transparent.

Supporting delivery of remote pulmonary rehabilitation across different healthcare contexts: A multi-national study

Purpose: This study aimed to understand factors that health professionals, from a variety of healthcare contexts and countries, believed support remote delivery of pulmonary rehabilitation (PR); and to develop a targeted intervention to support implementation of remote PR. Methods: A 3-phase participatory action-research process was employed, across three study hubs in three countries (NZ, India, USA), representing diverse healthcare delivery contexts. Phase 1 employed focus groups of health professionals working in PR; data were analysed qualitatively with transcripts coded against two implementation frameworks (Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR)). Findings informed development of an online toolbox to support delivery of remote PR (Phase 2), which was evaluated using semi-structured interviews (Phase 3). Results: 20 health professionals participated across all study phases. Factors considered to influence implementation of remote PR were consistent across diverse healthcare contexts and related to staffing availability, skills and confidence, and equipment and technology accessibility. An online toolbox provided support for enhancing knowledge and confidence, but was not able to address all implementation barriers. Discussion: Key factors to support clinicians deliver remote PR are common across different healthcare contexts, suggesting broader telerehabilitation implementation strategies may be applicable across healthcare environments.

Chlorhexidine-based versus non-chlorhexidine dressings to prevent catheter-related bloodstream infections: An evidence-based review

In patients with central venous catheters (CVCs) in situ, the development of catheter-related bloodstream infections (CRBSIs) is often linked with increased morbidity and mortality. Sterile gauze or transparent polyurethane dressings are conventionally used as extraluminal barriers; however, antimicrobial chlorhexidine CVC dressings could potentially reduce infection risk. This short evidence-based review examined the literature comparing the effectiveness of chlorhexidine-based CVC dressings against non-chlorhexidine dressings in reducing CRBSI occurrence. Four systematic reviews with meta-analysis were reviewed, all of which reported a statistically significant reduction in CRBSI occurrence on using chlorhexidine-based dressings. Further research is needed to determine the cost-effectiveness of chlorhexidine-based CVC dressings and their effectiveness in reducing CRBSIs in different catheter types and entry sites because infection risk is not uniform.

The Association of Organizational Readiness With Lung Cancer Screening Utilization

INTRODUCTION

Lung cancer screening is widely underutilized. Organizational factors, such as readiness for change and belief in the value of change (change valence), may contribute to underutilization. The aim of this study was to evaluate the association between healthcare organizations' preparedness and lung cancer screening utilization.

METHODS

Investigators cross-sectionally surveyed clinicians, staff, and leaders at10 Veterans Affairs from November 2018 to February 2021 to assess organizational readiness to implement change. In 2022, investigators used simple and multivariable linear regression to evaluate the associations between facility-level organizational readiness to implement change and change valence with lung cancer screening utilization. Organizational readiness to implement change and change valence were calculated from individual surveys. The primary outcome was the proportion of eligible Veterans screened using low-dose computed tomography. Secondary analyses assessed scores by healthcare role.

RESULTS

The overall response rate was 27.4% (n=1,049), with 956 complete surveys analyzed: median age of 49 years, 70.3% female, 67.6% White, 34.6% clinicians, 61.1% staff, and 4.3% leaders. For each 1-point increase in median organizational readiness to implement change and change valence, there was an associated 8.4-percentage point (95% CI=0.2, 16.6) and a 6.3-percentage point increase in utilization (95% CI= -3.9, 16.5), respectively. Higher clinician and staff median scores were associated with increased utilization, whereas leader scores were associated with decreased utilization after adjusting for other roles.

CONCLUSIONS

Healthcare organizations with higher readiness and change valence utilized more lung cancer screening. These results are hypothesis generating. Future interventions to increase organizations' preparedness, especially among clinicians and staff, may increase lung cancer screening utilization.

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

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

A Study of Medical Surgical Nurses Leaders' Evidence-Based Practice Attributes: Critical Implications for Practice

OBJECTIVE

The purpose of this study was to determine medical-surgical nurse leaders' evidence-based practice (EBP) attributes, perceived barriers to EBP, and whether there were differences in leaders' EBP competencies and EBP implementation by demographic and organizational factors.

BACKGROUND

Leaders are crucial to the development of cultures that support EBP implementation, but little is known about medical-surgical nurse leaders' capacity to perform this aspect of their role.

METHODS

A cross-sectional design using survey methodology was used. The survey contained demographic/work setting questions and 3 instruments to measure EBP beliefs, implementation, and competencies.

RESULTS

Senior leaders self-reported higher EBP attributes compared with nurses in other roles; nurses with an MSN or higher reported greater frequency of EBP implementation. A regression revealed that EBP competencies, EBP beliefs, having a DNP degree, and working in an Academy of Medical-Surgical Nurses Premier Recognition In the Specialty of Med-surg unit or a Pathway to Excellence® organization had significant, positive effects on EBP implementation scores ( R2 = 0.37).

CONCLUSIONS

Findings demonstrate there is a range of EBP beliefs and competencies, and barriers to EBP among medical-surgical nurse leaders. Because medical-surgical nursing is the largest acute care practice specialty in the United States and many other countries, leaders fully integrating EBP into their practice would be a substantial contribution to advancing EBP in healthcare.

Ready, set, go! The role of organizational readiness to predict adoption of a family caregiver training program using the Rogers' diffusion of innovation theory

BACKGROUND

Caregivers FIRST is an evidence-based program addressing gaps in caregivers' skills. In 2020, the Veterans Health Administration Caregiver Support Program (CSP) nationally endorsed Caregivers FIRST, offering credit in leadership performance plans to encourage all VA medical centers (VAMCs) to implement locally. This study examines the association of organizational readiness with VAMC adoption of Caregivers FIRST.

METHODS

In a cohort observational study, we surveyed CSP managers about their facilities' readiness to implement using the Organizational Readiness for Implementing Change (ORIC) instrument and compared change commitment and change efficacy domains among VAMCs "adopters" defined as delivering Caregivers FIRST within 1 year of the national announcement to those that did not ("non-adopters"). Within "adopters," we categorized time to adoption based on Rogers' diffusion of innovation theory including "innovators," "early adopters," "early majority," "late adopters," and "laggards." Organizational readiness and site characteristics (facility complexity, staffing levels, volume of applications for caregiver assistance services) were compared between "adopters," "non-adopters," and between time to adoption subcategories. Separate logistic regression models were used to assess whether ORIC and site characteristics were associated with early adoption among "adopters."

RESULTS

Fifty-one of 63 (81%) VAMCs with CSP manager survey respondents adopted Caregivers FIRST during the first year. ORIC change commitment and efficacy were similar for "adopters" and "non-adopters." However, sites that adopted earlier (innovators and early adopters) had higher ORIC change commitment and efficacy scores than the rest of the "adopters." Logistic regression results indicated that higher ORIC change commitment (odds ratio [OR] = 2.57; 95% confidence interval [CI], 1.11-5.95) and ORIC change efficacy (OR = 2.60; 95% CI, 1.12-6.03) scores were associated with increased odds that a VAMC was an early adopter (categorized as an "innovator," "early adopter", or "early majority"). Site-level characteristics were not associated with Caregivers FIRST early adoption.

CONCLUSIONS

To our knowledge, this study is the first to prospectively assess organizational readiness and the timing of subsequent program adoption. Early adoption was associated with higher ORIC change commitment and change efficacy and not site-level characteristics. These findings yield insights into the role of organizational readiness to accelerate program adoption.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03474380. Registered on March 22, 2018.

Practices Among Local Public Health Agencies to Support Evidence-Based Decision Making: A Qualitative Study

OBJECTIVES

Evidence-based decision making (EBDM) capacity in local public health departments is foundational to meeting both organizational and individual competencies and fulfilling expanded roles. In addition to on-the-job training, organizational supports are needed to prepare staff; yet, less is known in this area. This qualitative study explores supportive management practices instituted as part of a training and technical assistance intervention.

DESIGN

This qualitative study used a semistructured interview guide to elicit participants' descriptions and perceptions via key informant interviews. Verbatim transcripts were coded and thematic analyses were conducted.

SETTING

Local public health departments in a US Midwestern state participated in the project.

PARTICIPANTS

Seventeen middle managers and staff from 4 local health departments participated in remote, audio-recorded interviews.

INTERVENTION

Following delivery of a 3½-day in-person training, the study team met with health department leadership teams for department selection of supportive agency policies and procedures to revise or newly create. Periodic remote meetings included collaborative problem-solving, sharing of informational resources, and encouragement.

MAIN OUTCOME MEASURES

Included management practices instituted to support EBDM and impact on day-to-day work as described by the interview participants.

RESULTS

Leadership and middle management practices deemed most helpful included dedicating staff; creating specific guidelines; setting expectations; and providing trainings, resources, and guidance. Health departments with a preexisting supportive organizational culture and climat e were able to move more quickly and fully to integrate supportive management practices. Workforce development included creation of locally tailored overviews for all staff members and onboarding of new staff. Staff wanted additional hands-on skill-building trainings. Several worked with partners to incorporate evidence-based processes into community health improvement plans.

CONCLUSIONS

Ongoing on-the-job experiential learning is needed to integrate EBDM principles into day-to-day public health practice. Management practices established by leadership teams and middle managers can create supportive work environments for EBDM integration.

Individual and Contextual Factors Associated with Classroom Teachers' Intentions to Implement Classroom Physical Activity

Classroom-based physical activity (CPA) is an evidence-based practice that improves student physical activity outcomes, but national data suggest implementation is insufficient in US classrooms. The purpose of this study was to examine individual and contextual factors associated with elementary school teachers' intentions to implement CPA. We collected input survey data from 181 classroom teachers (10 schools; 98.4% participation among eligible teachers) across three separate cohorts to examine associations between individual and contextual constructs and future CPA implementation intentions. Data were analyzed using multilevel logistic regression. Individual-level characteristics of perceived autonomy for using CPA, perceived relative advantage/compatibility of CPA, and general openness to educational innovations were positively associated with intentions to implement CPA (p < 0.05). Teacher perceptions of contextual factors such as administrator support for CPA were also associated with implementation intentions. This study adds to prior evidence about the importance of theoretically determined constructs for understanding behavioral intentions among front-line implementers such as classroom teachers. Additional research is needed to evaluate interventions designed to change malleable factors, including teachers' perceptions, as well as changing school environments so that teachers perceive more autonomy to use CPA and have the training and resources that build skills for implementation.

Perceptual differences in nursing implementation leadership and climate: a cross-sectional study

BACKGROUND

The literature on perceptual differences between managers and staff regarding social dynamic factors (e.g., leadership, climate) in nursing settings is sparse. Addressing this gap in knowledge is critical for informing implementation efforts and improving patient and organizational outcomes. The purpose of this study was to test the perceptual differences regarding implementation leadership and implementation climate between nursing staff and their managers.

METHODS

This study was a secondary analysis of cross-sectional survey data collected in 2016-2017. The setting included 22 adult medical-surgical units nested in 7 acute care hospitals in the Eastern and Midwestern United States. Participants were registered nurses (N = 261) and nurse managers (N = 22) who completed an electronic survey consisting of the Implementation Leadership Scale (ILS), the Implementation Climate Scale (ICS), and demographic items. Differences in perception were analyzed at the unit level using structural equation modeling to develop latent difference score models (LDS). We assessed associations of the LDSs with manager ILS and ICS scores, years of nursing experience, and years of experience working on the current unit. The association of ILS LDS with the observed nursing staff ICS scores was also analyzed.

RESULTS

Higher manager scores on the ILS and ICS were associated with greater perceptual differences in implementation leadership and implementation climate. Greater years of experience as a nurse were associated with greater perceptual differences in ILS and ICS scores. Greater tenure on the unit was associated with smaller differences on the ILS knowledge domain. Greater perceptual differences regarding implementation leadership were associated with worse staff ratings of implementation climate.

CONCLUSIONS

Although this study observed significant relationships among manager ILS and ICS scores, staff-manager perceptual differences, and staff ratings of implementation climate in nursing settings, it is still unclear why perceptual differences in implementation leadership and climate exist and how to address them. Future studies are warranted to test the effect of perceptual differences on implementation and patient outcomes.

Implementation Leadership in the Point of Care Nursing Context: A Systematic Review Comparing Two Measurement Tools

Introduction

Implementation leadership (IL) are effective point of care (POC) nursing leadership behaviors that facilitate contexts conducive to the successful implementation of evidence-based practices (EBPs). However, no systematic evaluation of IL tools validated for the nursing context existed.

Aims

The purpose of this systematic review was to compare iterations of two IL measurement tools, the Implementation Leadership Scale (ILS) and the iLEAD, for application in a nursing context; and to critically appraise and summarize the methodological quality of studies assessing their psychometric properties.

Methods

A comprehensive search was conducted in four databases. Two reviewers independently screened titles and abstracts, reviewed full-text articles, and performed extraction into data tables. Statisticians appraised the quality control aspects. Findings were narratively summarized.

Results

A total of 247 records were included, where 10 for the ILS (including different versions) and one for the iLEAD met the inclusion criteria. Three studies evaluated the psychometric properties of the ILS in nursing, and its translations into Chinese and Greek. Content validity was deemed to be doubtful for both tools, but the ILS had adequate rating for comprehensiveness; methodological quality was very good for structural validity, internal consistency, hypothesis testing, and responsiveness where applicable for both scales, with the exception of cross-cultural validity which had ratings of adequate and inadequate for versions of the scales. Several study findings met the criteria for good measurement properties. No studies for either tool formally assessed feasibility.

Conclusion

Applying validated and contextually relevant tools to evaluate the capacity of nursing leadership to engage in IL in real-world contexts are needed. The ILS shows promise but requires further validation for contexts with diverse and multiple nursing leaders at the POC. Feasibility needs to be further studied.

Understanding implementation completion of tailored motivational interviewing in multidisciplinary adolescent HIV clinics

Background

Understanding the barriers and facilitators of implementation completion is critical to determining why some implementation efforts fail and some succeed. Such studies provide the foundation for developing further strategies to support implementation completion when scaling up evidence-based practices (EBPs) such as Motivational Interviewing.

Method

This mixed-methods study utilized the Exploration, Preparation, Implementation, and Sustainment framework in an iterative analytic design to compare adolescent HIV clinics that demonstrated either high or low implementation completion in the context of a hybrid Type III trial of tailored motivational interviewing. Ten clinics were assigned to one of three completion categories (high, medium, and low) based on percentage of staff who adhered to three components of implementation strategies. Comparative analysis of staff qualitative interviews compared and contrasted the three high-completion clinics with the three low-completion clinics.

Results

Results suggested several factors that distinguished high-completion clinics compared to low-completion clinics including optimism, problem-solving barriers, leadership, and staff stress and turnover.

Conclusions

Implementation strategies targeting these factors can be added to EBP implementation packages to improve implementation success.

Plain Language Summary

While studies have begun to address adherence to intervention techniques, this is one of the first studies to address organizational adherence to implementation strategies. Youth HIV providers from different disciplines completed interviews about critical factors in both the inner and outer context that can support or hinder an organization's adherence to implementation strategies. Compared to less adherent clinics, more adherent clinics reported more optimism, problem-solving, and leadership strengths and less staff stress and turnover. Implementation strategies addressing these factors could be added to implementation packages to improve implementation success.

Identifying and prioritising the key components of a Quality Improvement Network for allied health professionals and psychological therapists: a group concept mapping project

INTRODUCTION

Despite growing enthusiasm for quality improvement (QI), the complexities of modern healthcare continue to create gaps in our ability to consistently deliver the most effective and efficient care for patients, and improvement activities often fail to achieve widespread uptake even when there is robust evidence of their benefits.

METHODS

We undertook a novel, mixed methods evaluation and planning project using group concept mapping (GCM) methodology to identify and prioritise the ways in which our recently established Quality Improvement Network (QIN) could support allied health professionals, psychological therapists and administrative staff in their daily work to improve patient outcomes and experience. Mid-level leaders across our therapy services department contributed towards a statement generation activity and individually sorted these statements into themes. Each statement was rated for perceived importance and current success. Multidimensional scaling and hierarchical cluster analysis were applied to the sorted data to produce themed clusters of ideas within concept maps. Priority values were applied to these maps to identify key areas for future QIN activity.

RESULTS

Overall, 34 participants took part in ideas generation, 20 in sorting and 30 in the rating activity. A five-item cluster map was agreed on, containing the following named clusters: data support; practical skills and training; time and resources; embedding a QI culture; and sharing ideas and working together. Statements contained within each of the five clusters highlight the importance of supporting a range of activities spanning the technical and human aspects of QI at an individual, group/team, organisation and wider systems level.

CONCLUSION

GCM provided a structured and systematic approach for identifying the perceived support needs of allied health professionals, psychological therapists and administrative support staff in relation to QI. The findings from this project provide a useful benchmark from which to track targeted QI support in an applied healthcare setting.

Trends in guideline implementation: an updated scoping review

Background

Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review.

Methods

We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics.

Results

We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks (n=25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers (n=59) most often consulted literature (60%). Those that engaged stakeholders (n=42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions.

Conclusions

Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact.

Trial registration

The protocol was registered with Open Science Framework (https://osf.io/4nxpr) and published in JBI Evidence Synthesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01223-6.

The effect of multicomponent approach in enhancing the level of confidence with evidence-based practice activities and promoting evidence-based practice culture among nurses in a clinical setting in the United Arab Emirates

AIM

The aim of this work is to examine the effect of multicomponent interventions on enhancing the level of confidence of staff nurses with evidence-based practice in an acute care hospital in the United Arab Emirates.

BACKGROUND

Evidence-based practice is one of the strategic pillars of nursing practice and a key to organizational success. To effectively implement and sustain evidence-based practice programmes in clinical sites, well-designed implementations can promote staff attitude, knowledge, skills, and confidence in translating research evidence into optimal patient care.

METHODS

Experienced and bachelor prepared nurse managers in collaboration with the clinical resource nurse undertook condensed staff training and interventions for the evidence-based practice programme, where 70 registered nurses participated. The intervention was conducted over a period of time extending from December 2019 until December 2020. The study design is quasi-experimental using the pre- and post-Self Efficacy Assessment tool to gauge the nurses' confidence in evidence-based practice. Also, SPSS software was used to explore the effect of the programme.

RESULTS

Higher significant score on the evidence-based nursing practice self-efficacy scale postprogramme was noted (t = -7.667 and p value <.001).

CONCLUSION

Participating in a well-structured evidence-based practice programme would positively enhance the nurse's confidence in the programme implementation and promote an evidence-based practice culture in clinical settings.

IMPLICATIONS FOR NURSING MANAGERS

Nurse managers must recognize their critical role in promoting evidence-based practice among nurses. A focused and well-designed intervention may assist in establishing a culture of evidence-based practice to ensure the best patient outcome.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

A Feeling of Ambiguity: A Qualitative Content Analysis of Managers' Experiences of Evidence-Based Practice in Swedish Primary Care

Background

The Primary care manager plays a vital role in promoting a research culture in the healthcare center. The position involves both the implementation of organizational directives and patient care. The research culture and use of evidence influence each individual healthcare professional and ultimately the quality of patient care.

Purpose

To describe primary healthcare managers’ understanding of evidence-based practice in the Swedish primary healthcare context and their ability to influence its implementation.

Methodology

Qualitative content analysis of data collected in individual interviews.

Results

In general, managers expressed a positive view toward the use of evidence in daily practice. However, they were sometimes hesitant about fully implementing evidence-based results. This was mostly attributed to the struggle of balancing finances and allocating sufficient time for staff to keep up with and engage in evidence-based practice.

Conclusion

The organizational culture impacts the mind-set of all co-workers including managers. Those managers influenced by traditions and norms may fall into the trap of devaluing the benefit of research and evidence. The inherent feeling of being alone and without guidance in some matters related to evidence-based practice inevitably leads to inconsistency and ambiguity. The use of clinical pathways that constitute one form of evidence has become a substitute for proper, careful, individual investigation, implementation, and evaluation of each patient case. This means that managers experience moral and physical stress when trying to meet organizational, staff, and patient demands.

Practice Implication

Awareness of managers’ influence and experience of working according to evidence-based practice is valuable to gain an insight into how Swedish primary healthcare functions at local level. Illuminating and discussing evidence-based practice is an assurance of quality that contributes to many aspects of the overall safety of care.

Assessing readiness to implement patient navigator programs in Toronto, Canada

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Corrigendum: Implementation of Therapeutic Virtual Reality Into Psychiatric Care: Clinicians' and Service Managers' Perspectives

[This corrects the article DOI: 10.3389/fpsyt.2021.791123.].

Development and Refinement of the American Occupational Therapy Association's Knowledge Translation Toolkit

IMPORTANCE

Occupational therapy practitioners are expected to translate promising discoveries from empirical research into routine practice with their clients. However, complex barriers can influence practitioners' knowledge translation (KT) efforts, leading the American Occupational Therapy Association's Evidence-Based Practice (EBP) group to develop the KT Toolkit tailored to the perceived needs of occupational therapists and occupational therapy assistants.

OBJECTIVE

To identify common barriers to implementing EBPs and potential strategies to support EBP uptake.

DESIGN

Cross-sectional survey.

SETTING

United States.

PARTICIPANTS

Occupational therapy practitioners.

OUTCOMES AND MEASURES

Data underwent descriptive and directed content analysis, the latter of which was guided by the Consolidated Framework for Implementation Research.

RESULTS

Occupational therapy survey respondents (N = 818) identified common EBP implementation barriers (e.g., lack of time and resources, difficulty understanding research findings). Initial KT Toolkit content was developed to address these barriers and included resources for searching for, analyzing, and applying evidence in practice.

CONCLUSIONS AND RELEVANCE

Survey findings have informed the development of the KT Toolkit, which includes resources designed to support occupational therapy practitioners' EBP implementation efforts. This KT Toolkit is available at AOTA.org and will be continuously revised and updated on an ongoing basis. What This Article Adds: Several barriers limit the extent to which occupational therapy practitioners can implement evidence with their client populations. The KT Toolkit is directly informed by practitioner input and provides resources to support practitioners in their efforts to translate knowledge into real-world practice.

Feasibility and implementation fidelity of a co-designed intervention to promote in-hospital mobility among older medical patients-the WALK-Copenhagen project (WALK-Cph)

BACKGROUND

Mobility interventions can prevent functional decline among older patients, but implementation of such interventions may be complicated by barriers in the clinical setting. The WALK-Copenhagen project (WALK-Cph) is aimed at promoting a 24-h mobility among older medical patients during hospitalization. The WALK-Cph intervention was co-designed by researchers and stakeholders to tailor the intervention to the clinical context. The aim of this study was to investigate the feasibility and implementation fidelity of the WALK-Cph intervention before evaluating clinical effectiveness in a randomized controlled trial (ClinicalTrials.gov NCT03825497).

METHODS

The WALK-Cph intervention consisted of six components: a welcome folder explaining the importance of in-hospital activity, a WALK-plan prescribing up to three daily walking sessions during and after hospitalization, a WALK-path in the hallway that patients were motivated to use daily, exercise posters in the hallways and bedrooms, self-service on beverages and clothes, and discharge with a WALK-plan. The present study reports on phase 2 of WALK-Cph and consists of a feasibility and a fidelity component. The study was conducted at the two WALK-Cph intervention departments after the initiation of the WALK-Cph intervention. A cohort of older medical patients (+65) was recruited for the feasibility study to assess recruitment and data collection procedures and the method for assessment of activity. Simultaneously, implementation fidelity was assessed by observing clinical practice and intervention delivery at the intervention departments.

RESULTS

A feasibility cohort of 48 patients was included. Inclusion was considered feasible with recruitment rates between 62% and 70% of all eligible patients. Also, data collection was conducted without obstacles, and all patients accepted to wear activity monitors. The fidelity observations showed that three of the six intervention components were partially implemented as planned whereas three components were not implemented as planned.

CONCLUSION

The WALK-Cph intervention was found feasible, and although the intervention was not implemented with fidelity, the level of fidelity was considered sufficient to continue with further testing of the WALK-Cph intervention in a large-scale trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03825497 (retrospectively registered). Protocol PubMed ID (PMID): 29523569.

Implementation of a complex intervention to reduce hospitalizations from nursing homes: a mixed-method evaluation of implementation processes and outcomes

Background | objective

To evaluate the implementation of three intervention elements to reduce hospitalizations in nursing home residents.

Design

Convergent mixed-method design within a hybrid type-2 effectiveness-implementation study.

Setting

Eleven nursing homes in the German-speaking region of Switzerland.

Participants

Quantitative data were collected from 573 care workers; qualitative data were collected from 108 care workers and the leadership from 11 nursing homes.

Intervention

Three intervention elements targeting care workers were implemented to reduce unplanned hospitalizations: (1) the STOP&WATCH instrument for early recognition of changes in resident condition; (2) the ISBAR instrument for structured communication; and (3) specially-trained INTERCARE nurses providing on-site geriatric support. Multifaceted implementation strategies focusing both on the overall nursing home organization and on the care workers were used.

Methods

The quantitative part comprised surveys of care workers six- and twelve-months post-intervention. The intervention’s acceptability, feasibility and uptake were assessed using validated and self-developed scales.

Qualitative data were collected in 22 focus groups with care workers, then analyzed using thematic analysis methodology. Data on implementation processes were collected during implementation meetings with nursing home leadership and were analyzed via content analysis. Findings were integrated using a complementary approach.

Results

The ISBAR instrument and the INTERCARE nurse role were considered acceptable, feasible, and taken up by > 70% of care workers. The STOP&WATCH instrument showed the lowest acceptance (mean: 68%), ranging from 24 to 100% across eleven nursing homes. A combination of factors, including the amount of information received, the amount of support provided in daily practice, the users’ perceived ease of using the intervention and its adaptations, and the intervention’s usefulness, appeared to influence the implementation’s success. Two exemplary nursing homes illustrated context-specific implementation processes that serve as either barriers or facilitators to implementation.

Conclusions

Our findings suggest that, alongside the provision of information shortly before intervention start, constant daily support is crucial for implementation success. Ideally, this support is provided by designated and trained individuals who oversee implementation at the organizational and unit levels. Leaders who seek to implement interventions in nursing homes should consider their complexity and their consequences for workflow to optimize implementation processes accordingly.

Trial registration

This study was registered at clinicaltrials.gov (NCT03590470) on the 18/06/2018.

"It's good to feel like you're doing something": a qualitative study examining state health department employees' views on why ineffective programs continue to be implemented in the USA

Background

Mis-implementation, the inappropriate continuation of programs or policies that are not evidence-based or the inappropriate termination of evidence-based programs and policies, can lead to the inefficient use of scarce resources in public health agencies and decrease the ability of these agencies to deliver effective programs and improve population health. Little is known about why mis-implementation occurs, which is needed to understand how to address it. This study sought to understand the state health department practitioners’ perspectives about what makes programs ineffective and the reasons why ineffective programs continue.

Methods

Eight state health departments (SHDs) were selected to participate in telephone-administered qualitative interviews about decision-making around ending or continuing programs. States were selected based on geographic representation and on their level of mis-implementation (low and high) categorized from our previous national survey. Forty-four SHD chronic disease staff participated in interviews, which were audio-recorded and transcribed verbatim. Transcripts were consensus coded, and themes were identified and summarized. This paper presents two sets of themes, related to (1) what makes a program ineffective and (2) why ineffective programs continue to be implemented according to SHD staff.

Results

Participants considered programs ineffective if they were not evidence-based or if they did not fit well within the population; could not be implemented well due to program restraints or a lack of staff time and resources; did not reach those who could most benefit from the program; or did not show the expected program outcomes through evaluation. Practitioners described several reasons why ineffective programs continued to be implemented, including concerns about damaging the relationships with partner organizations, the presence of program champions, agency capacity, and funding restrictions.

Conclusions

The continued implementation of ineffective programs occurs due to a number of interrelated organizational, relational, human resources, and economic factors. Efforts should focus on preventing mis-implementation since it limits public health agencies’ ability to conduct evidence-based public health, implement evidence-based programs effectively, and reduce the high burden of chronic diseases. The use of evidence-based decision-making in public health agencies and supporting adaptation of programs to improve their fit may prevent mis-implementation. Future work should identify effective strategies to reduce mis-implementation, which can optimize public health practice and improve population health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00252-4.

Implementation of Therapeutic Virtual Reality Into Psychiatric Care: Clinicians' and Service Managers' Perspectives

Objectives: Virtual reality (VR) has emerged as a highly promising tool for assessing and treating a range of mental illnesses. However, little is known about the perspectives of key stakeholders in mental healthcare, whose support will be critical for its successful implementation into routine clinical practise. This study aimed to explore the perspectives of staff working in the private mental health sector around the use of therapeutic VR, including potential implementation barriers and facilitators. Methods: Semi-structured qualitative interviews were conducted with cross-disciplinary clinicians (n = 14) and service managers (n = 5), aged 28-70 years working in a major private mental health hospital in Victoria, Australia. Transcripts were analysed using general inductive coding to allow themes to naturally emerge. Results: Three major themes were identified: clinical factors (four subthemes), organisational factors (five subthemes), and professional factors (three subthemes). The themes encompassed enabling factors and potential barriers that need to be addressed for successful implementation of VR. Clinical factors highlighted the influence of knowledge or perceptions about appropriate clinical applications, therapeutic efficacy, safety and ethical concerns, and patient engagement. Organisational factors emphasised the importance of service contexts, including having a strong business case, stakeholder planning, recruitment of local opinion leaders to champion change, and an understanding of resourcing challenges. Professional factors highlighted the need for education and training for staff, and the influence of staff attitudes towards technology and perceived usability of VR. Conclusions: In addition to enabling factors, potential implementation barriers of therapeutic VR were identified, including resourcing constraints, safety and ethical concerns, negative staff attitudes towards technology and VR system limitations. Future dissemination should focus on addressing knowledge and skills gaps and attitudinal barriers through development of clinical guidelines, training programs, and implementation resources (e.g., adoption decision tools, consultation opportunities).

The roles, activities and impacts of middle managers who function as knowledge brokers to improve care delivery and outcomes in healthcare organizations: a critical interpretive synthesis

Background

Middle Managers (MMs) are thought to play a pivotal role as knowledge brokers (KBs) in healthcare organizations. However, the role of MMs who function as KBs (MM KBs) in health care is under-studied. Research is needed that contributes to our understanding of how MMs broker knowledge in health care and what factors influence their KB efforts.

Methods

We used a critical interpretive synthesis (CIS) approach to review both qualitative and quantitative studies to develop an organizing framework of how MMs enact the KB role in health care. We used compass questions to create a search strategy and electronic searches were conducted in MEDLINE, CINAHL, Social Sciences Abstracts, ABI/INFORM, EMBASE, PubMed, PsycINFO, ERIC and the Cochrane Library. Searching, sampling, and data analysis was an iterative process, using constant comparison, to synthesize the results.

Results

We included 41 articles (38 empirical studies and 3 conceptual papers) that met the eligibility criteria. No existing review was found on this topic. A synthesis of the studies revealed 12 MM KB roles and 63 associated activities beyond existing roles hypothesized by extant theory, and we elaborate on two MM KB roles: 1) convincing others of the need for, and benefit of an innovation or evidence-based practice; and 2) functioning as a strategic influencer. We identified organizational and individual factors that may influence the efforts of MM KBs in healthcare organizations. Additionally, we found that the MM KB role was associated with enhanced provider knowledge, and skills, as well as improved organizational outcomes.

Conclusion

Our findings suggest that MMs do enact KB roles in healthcare settings to implement innovations and practice change. Our organizing framework offers a novel conceptualization of MM KBs that advances understanding of the emerging KB role that MMs play in healthcare organizations. In addition to roles, this study contributes to the extant literature by revealing factors that may influence the efforts and impacts of MM KBs in healthcare organizations. Future studies are required to refine and strengthen this framework.

Trial registration

A protocol for this review was not registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07387-z.

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

Background:

Most evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD) and anxiety disorders include exposure; however, in community settings, the implementation of exposure lags behind other EBT components. Clinician-level determinants have been consistently implicated as barriers to exposure implementation, but few organizational determinants have been studied. The current study examines an organization-level determinant, implementation climate, and clinician-level determinants, clinician demographic and background factors, as predictors of attitudes toward exposure and changes in attitudes following training.

Method:

Clinicians (n = 197) completed a 3-day training with 6 months of twice-monthly consultation. Clinicians were trained in cognitive behavioral therapy (CBT) for anxiety, depression, behavior problems, and trauma-focused CBT (TF-CBT). Demographic and background information, implementation climate, and attitudes toward exposure were assessed in a pre-training survey; attitudes were reassessed at post-consultation. Implementation climate was measured at the aggregated/group-level and clinician-level.

Results:

Attitudes toward exposure significantly improved from pre-training to post-consultation (t(193) = 9.9, p < .001; d = 0.71). Clinician-level implementation climate scores did not predict more positive attitudes at pre-training (p > .05) but did predict more positive attitudes at post-consultation (ß = −2.46; p < .05) and greater changes in those attitudes (ß = 2.28; p < .05). Group-level implementation climate scores did not predict attitudes at pre-training, post-consultation, or changes in attitudes (all ps > .05). Higher frequency of self-reported CBT use was associated with more positive attitudes at pre-training (ß = −0.81; p < .05), but no other clinician demographic or background determinants were associated with attitudes at post-consultation (all p > .05) or with changes in attitudes (all p > .05).

Conclusions:

Clinician perceptions of implementation climate predicted greater improvement of attitudes toward exposure following EBT training and consultation. Findings suggest that organizational determinants outside of training impact changes in clinicians’ attitudes. Training in four EBTs, only two of which include exposure as a component, resulted in positive changes in clinicians’ attitudes toward exposure, which suggests non-specialty trainings can be effective at changing attitudes, which may enable scale-up.

Exposure is highly effective for treating trauma symptoms and anxiety-based disorders, but it is not commonly used in community mental health settings. Clinicians who endorsed higher expectations, support, and rewards for using exposure in their agency had more positive attitudes toward exposure after training and consultation. Additionally, clinicians who endorsed that exposure is expected, supported, and rewarded in their agency showed a greater improvement in attitudes throughout the training process. Organizational culture can affect clinicians’ attitude changes in the training process, and therefore should become a focus of training efforts.

Learning needs assessment for multi-stakeholder implementation science training in LMIC settings: findings and recommendations

Background

Despite significant progress in the field of implementation science (IS), current training programs are inadequate to meet the global need, especially in low-and middle-income countries (LMICs). Even when training opportunities exist, there is a “knowledge-practice gap,” where implementation research findings are not useful to practitioners in a field designed to bridge that gap. This is a critical challenge in LMICs where complex public health issues must be addressed. This paper describes results from a formal assessment of learning needs, priority topics, and delivery methods for LMIC stakeholders.

Methods

We first reviewed a sample of articles published recently in Implementation Science to identify IS stakeholders and assigned labels and definitions for groups with similar roles. We then employed a multi-step sampling approach and a random sampling strategy to recruit participants (n = 39) for a semi-structured interview that lasted 30–60 min. Stakeholders with inputs critical to developing training curricula were prioritized and selected for interviews. We created memos from audio-recorded interviews and used a deductively created codebook to conduct thematic analysis. We calculated kappa coefficients for each memo and used validation techniques to establish rigor including incorporating feedback from reviewers and member checking.

Results

Participants included program managers, researchers, and physicians working in over 20 countries, primarily LMICs. The majority had over 10 years of implementation experience but fewer than 5 years of IS experience. Three main themes emerged from the data, pertaining to past experience with IS, future IS training needs, and contextual issues. Most respondents (even with formal training) described their IS knowledge as basic or minimal. Preferences for future training were heterogeneous, but findings suggest that curricula must encompass a broader set of competencies than just IS, include mentorship/apprenticeship, and center the LMIC context.

Conclusion

While this work is the first systematic assessment of IS learning needs among LMIC stakeholders, findings reflect existing research in that current training opportunities may not meet the demand, trainings are too narrowly focused to meet the heterogeneous needs of stakeholders, and there is a need for a broader set of competencies that moves beyond only IS. Our research also demonstrates the timely and unique needs of developing appropriately scoped, accessible training and mentorship support within LMIC settings. Therefore, we propose the novel approach of intelligent swarming as a solution to help build IS capacity in LMICs through the lens of sustainability and equity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00238-2.

Applying a scoping review approach for identifying effective implementation strategies in oral health settings

Dental service providers have limited capacity to identify strategies to implement evidence-based practices (EBPs). We developed a rigorous yet parsimonious scoping review approach to identify, select, and rate implementation strategies based on an oral health system context. From 153 strategies identified, we selected the top 11 strategies, which had a moderate level of support of evidence and where managers were the main actors. The main actions were to educate, remind, structure, and influence. Targets included dentists, dental hygienists, and assistants and managers from a large prepaid dental care delivery system. This approach responds to calls for rapid and innovative methods to implement EBPs in oral health.

Contextual factors influencing a training intervention aimed at improved maternal and newborn healthcare in a health zone of the Democratic Republic of Congo

Background

Maternal and neonatal mortality and morbidity in the Democratic Republic of Congo (DRC) are among the highest worldwide. As part of a quality improvement programme in a health zone in the DRC aimed at contributing to reduced maternal and neonatal mortality and morbidity, a three-pillar training intervention around childbirth was developed and implemented in collaboration between Swedish and Congolese researchers and healthcare professionals. The aim of this study is to explore contextual factors influencing this intervention.

Methods

A qualitative research design was used, with data collected through focus group discussions (n = 7) with healthcare professionals involved in the intervention before and at the end (n = 9). Transcribed discussions were inductively analysed using content analysis.

Results

Three generic categories describe the contextual factors influencing the intervention: i) Incentives motivated participants’ efforts to begin a training programme; ii) Involving the local health authorities was important; and (iii) Having physical space, electricity, and equipment in place was crucial.

Conclusions

This study and similar ones highlight that incentives of various types are crucial contextual factors that influence training interventions, and have to be considered already in the planning of such interventions. One such factor is expectations of monetary incentives. To meet this in a small research project like ours would require a reduction of the scale and thus limit the implementation of new evidence-based knowledge into practice aimed at reducing maternal mortality and morbidity.

Organizational capacity for patient and family engagement in hospital planning and improvement: interviews with patient/family advisors, managers and clinicians

BACKGROUND

Patient and family engagement (PE) in healthcare planning and improvement achieves beneficial outcomes and is widely advocated, but a lack of resources is a critical barrier. Little prior research studied how organizations support engagement specifically in hospitals.

OBJECTIVE

We explored what constitutes hospital capacity for engagement.

METHODS

We conducted descriptive qualitative interviews and complied with criteria for rigour and reporting in qualitative research. We interviewed patient/family advisors, engagement managers, clinicians and executives at hospitals with high engagement activity, asking them to describe essential resources or processes. We used content analysis and constant comparison to identify themes and corresponding quotes and interpreted findings by mapping themes to two existing frameworks of PE capacity not specific to hospitals.

RESULTS

We interviewed 40 patient/family advisors, patient engagement managers, clinicians and corporate executives from nine hospitals (two < 100 beds, four 100 + beds, three teaching). Four over-arching themes about capacity considered essential included resources, training, organizational commitment and staff support. Views were similar across participant and hospital groups. Resources included funding and people dedicated to PE and technology to enable communication and collaboration. Training encompassed initial orientation and project-specific training for patient/family advisors and orientation for new staff and training for existing staff on how to engage with patient/family advisors. Organizational commitment included endorsement from the CEO and Board, commitment from staff and continuous evaluation and improvement. Staff support included words and actions that conveyed value for the role and input of patient/family advisors. The blended, non-hospital-specific framework captured all themes. Hospitals of all types varied in the availability of funding dedicated to PE. In particular, reimbursement of expenses and compensation for time and contributions were not provided to patient/family advisors. In addition to skilled engagement managers, the role of clinician or staff champions was viewed as essential.

CONCLUSION

The findings build on prior research that largely focused on PE in individual clinical care or research or in primary care planning and improvement. The findings closely aligned with existing frameworks of organizational capacity for PE not specific to hospital settings, which suggests that hospitals could use the blended framework to plan, evaluate and improve their PE programs. Further research is needed to yield greater insight into how to promote and enable compensation for patient/family advisors and the role of clinician or staff champions in supporting PE.