Implementation of change in health care in Sweden: a qualitative study of professionals' change responses

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.

The effect of regional transmural agreements on the information transfer of frail older patients

INTRODUCTION

Frail older patients are at risk for many complications when admitted to the hospital. Multidisciplinary regional transmural agreements (RTA) in which guidelines were set concerning the information transfer of frail older patients might improve outcomes. We aim to investigate the effect of implementation of the RTA on the completeness of the information transfer of frail older patients when admitted to and discharged from the hospital.

METHODS

This is a retrospective cohort study in which we collected data from 400 randomly selected hospitalized frail older patients (70+) before the implementation of the RTA, January through March 2021, and after, October through December 2021. The cohort was split up into four groups, which determined what correspondence would be checked (referral letter by General Practitioner (GP) and three groups of 'hospital letters': ED letter upon admittance, clinical discharge letter to the elderly care physician and clinical discharge letter to the GP. We assessed for mention of frailty, a medication list and mention of resuscitation orders.

RESULTS

In the period before implementation the mean age of patients was 82.6 years (SD 7.4) and 101 were female (50.5%), after implementation mean age was 82.3 (SD 6.9) and 112 were female (56.0%). Frailty was mentioned in hospital letters in 12.7% before and 15.3% after implementation (p = 0.09). More GP referral letters were present after implementation (32.0% vs. 54.0%, p = 0.03), however frailty was mentioned only in 12.5% before and 7.4% after (p = 0.58). There was a good handover of medication lists from the hospital (89.3% before, 94% after, p = 0.20) and even better from the GP (93.8% before, 100% after, p = 0.19). Resuscitation orders were mentioned in 59.3% of letters from the hospital before implementation and 57.3% after (p = 0.77), which is higher than in the referral letters (18.8% before and 22.2% after (p = 0.91).

DISCUSSION

The implementation of RTA improved the number of GP referral letters present; however, it did not lead to other significant improvements in communication between the hospital and the GP's. Frailty and resuscitation orders are still frequently not mentioned in the reports. After a successful reimplementation, the improvements of outcomes could be investigated.

Attitudes toward organizational change and their association with exhaustion in a sample of Italian police workers

Introduction

Change management is an important topic for organizations and some personal characteristics may help or hinder coping with change.

Methods

The aim of the present study was to find out whether attitudes toward organizational change can predict work-related exhaustion in a sample of police workers (N = 532) in northern Italy. Differences between groups in relation to role (police officers vs. other roles) and gender were also considered.

Results

The results of hierarchical regression showed that change beliefs were negatively associated to exhaustion, while resistance to change was positively related to exhaustion; role and gender were also significantly and positive associated with the dependent variable. Regarding differences between groups, police officers had lower positive change beliefs and higher levels of exhaustion compared to workers in other roles. Regarding gender, women reported higher levels of exhaustion than men.

Discussion

The results of the present study provide further insights into what aspects should be considered when promoting organizational change in the police work context.

Facilitators and Barriers to a Hospital-Based Communication Skills Training Programme: An Interview Study

This study aimed to investigate the facilitators and barriers experienced by the department management (DMs) and communication skills trainers (trainers) during the implementation of a 3-day communication skills training (CST) programme for healthcare professionals (HCPs). Thus, we conducted semi-structured interviews with 23 DMs and 10 trainers from 11 departments concurrently implementing the CST programme. Thematic analysis was undertaken to elucidate the themes across the interviews. Five themes were developed: resource consumption; obstacles; management support; efforts and outcomes; and a lack of systematic follow-up. Although the DMs and trainers were largely in agreement, the theme of a lack of systematic follow-up was derived exclusively from the trainers, as were two of the subthemes within obstacles: (b) seniority, profession, and cultural differences, and (c) the trainers' competencies. The greatest perceived barrier was resource consumption. In addition, DMs found planning and staff resistance to be a challenge. However, the HCPs' resistance diminished or even changed to satisfaction after participating. The mandatory approach served as both a facilitator and a barrier; DMs' support was an essential facilitator. Explicit communication related to resource demands, planning, and participation is crucial, as is management support and the allocation of resources.

Well-being in long-term care: an ode to vulnerability

In health care, well-being is considered to be composed of multiple interacting dimensions and to regard the subjective (affective and cognitive) evaluation of these dimensions. These dimensions are often referred to as physical, psychological, and social domains of life. Although there are various disease-specific and group-specific conceptual approaches, starting from a universal perspective provides a more inclusive approach to well-being. Indeed, universal approaches to well-being have striking overlaps with dementia-specific approaches. Although many initiatives have been launched to promote person-centered care and attention for well-being in recent decades, the current COVID pandemic showed that the primary focus in (Dutch) long-term care was still on physical health. However, a well-being perspective can be a central base of care: it is a means to include positive aspects, and it can be applied when addressing problems such as challenging behavior in the sense that both are about needs. Furthermore, providing care from this perspective is not only about the well-being of frail people and their loved ones but also about the well-being and needs of the involved professionals. Increasingly, research shows the importance of the quality of the resident-carer relationship, the carer's behavior, and their well-being for improving the well-being of residents. Applying the care approaches 'attentiveness in care' and relationship-centered care can contribute to the well-being of all involved stakeholders as these uphold the reciprocity of care relationships and take the values and attitudes, but also the vulnerability of those involved, into account.

Trust and Nursing: Delivering Effective Change Management and Driving a Culture of Innovation

Trust is foundational for all interpersonal communication and activities in an increasingly networked and interdependent world. Trust is also essential to the effective delivery of health care and for building collegial environments rich in innovation and readily adaptable to change. As the world's most trusted profession and vested peer collaborators across interprofessional health care teams, nurses are uniquely qualified to shepherd change and foster an innovation mindset across organizations and systems. Innovation requires creative teams that are appropriately resourced and supported, and team-based innovation requires time, space, and safety for groups to realize their full potential and maximize contributions. Appropriate staffing, resourcing, internal engagement, and external partnerships are essential to successfully conceive, launch, sustain, and deliver change initiatives that successfully challenge the status quo. Diverse teams are vital to enhancing the performance, effectiveness, and delivery of change and innovation. Effective change management and innovation practices require courage and imagination, skills that nurses have long possessed. Nurses are uniquely equipped to champion human-centered design through all phases of innovation while bringing knowledge of patients and communities to bear in ways that deliver innovation, are respectful of challenges, and mindful of opportunities to strengthen individuals and communities.

Using nudges to promote clinical decision making of healthcare professionals: A scoping review

Nudging has been discussed in the context of policy and public health, but not so much within healthcare. This scoping review aimed to assess the empirical evidence on how nudging techniques can be used to affect the behavior of healthcare professionals (HCPs) in clinical settings. A systematic database search was conducted for the period January 2010-December 2020 using the PRISMA extension for Scoping Review checklist. Two reviewers independently screened each article for inclusion. Included articles were reviewed to extract key information about each intervention, including purpose, target behavior, measured outcomes, key findings, nudging strategies, intervention objectives and their theoretical underpinnings. Two independent dimensions, building on Kahneman's System 1 and System 2, were used to describe nudging strategies according to user action and timing of their implementation. Of the included 51 articles, 40 reported statistically significant results, six were not significant and two reported mixed results. Thirteen different nudging strategies were identified aimed at modifying four types of HPCs' behavior: prescriptions and orders, procedure, hand hygiene, and vaccination. The most common nudging strategy employed were defaults or pre-orders, followed by alerts or reminders, and active choice. Many interventions did not require any deliberate action from users, here termed passive interventions, such as automatically changing prescriptions to their generic equivalent unless indicated by the user. Passive nudges may be successful in changing the target outcome but may go unnoticed by the user. Future work should consider the broader ethical implications of passive nudges.

The processes involved in the establishment of user-provider partnerships in severe psychiatric illnesses: a scoping review

PURPOSE

With the rising relevance of person-centred care, initiatives towards user-led decision making and designing of care services have become more frequent. This designing of care services can be done in partnership, but it is unclear how. The aim of this scoping review was to identify for mental health services, what user-provider partnerships are, how they arise in practice and what can facilitate or hinder them.

METHODS

A scoping review was conducted to obtain a broad overview of user provider partnerships in severe mental illness. Data was inductively analysed using a conventional content analysis approach, in which meaning was found in the texts.

RESULTS

In total, 1559 titles were screened for the eligibility criteria and the resulting 22 papers found relevant were analysed using conventional content analysis. The identified papers had broad and differing concepts for user-provider partnerships. Papers considered shared decision making and user-involvement as partnerships. Mechanisms such as open communication, organisational top-down support and active participation supported partnerships, but professional identity, power imbalances and stress hindered them. Users can be impeded by their illness, but how to deal with these situations should be formalised through contracts.

CONCLUSION

The field of research around user-provider partnerships is scattered and lacks consensus on terminology. A power imbalance between a user and a provider is characteristic of partnerships in mental healthcare, which hinders the necessary relationship building allowing partnerships to arise. This power imbalance seems to be closely linked to professional identity, which was found to be difficult to change.

Implementation of a Health Promotion Practice Using Individually Targeted Lifestyle Interventions in Primary Health Care: Protocol for the "Act in Time" Mixed Methods Process Evaluation Study

Background

There is growing evidence that noncommunicable diseases (NCDs) can be attributable to unhealthy lifestyle habits. However, there has been little application of this knowledge in primary health care (PHC).

Objective

This study aims to evaluate the process and outcomes of a multifaceted implementation strategy for a healthy lifestyle-promoting practice in a PHC setting. This practice is based on national guidelines targeting unhealthy lifestyle habits with a potential risk for NCDs.

Methods

A pre-post implementation study design with a control group is used in a PHC setting in central Sweden. The Medical Research Council guidelines for process evaluation of complex interventions will be applied. The implementation process and outcomes will be assessed using a mix of qualitative and quantitative methods. A strategic sample of up to 6 PHC centers will be included as intervention centers, which will receive a 12-month multifaceted implementation strategy. Up to 6 matched PHC centers will serve as controls. Core components in the implementation strategy are external and internal facilitators in line with the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and the Astrakan change leadership model. Data will be collected at baseline, during the implementation phase, and 4-6 months after the implementation strategy. Questionnaires will be sent to roughly 500 patients in every PHC center and 200 health care professionals (HCPs) before and after implementation. In addition, purposeful sampling will be used for interviews and focus group discussions with managers, HCPs, patient representatives, and internal and external facilitators. Use of data from medical records and activity logs will be an additional data source.

Results

Recruitment of PHC centers began in March 2021 and ended in Spring 2022. Based on the planned timeline with the 12-month implementation strategy and 4-6-month follow-up, we expect to collect the final data in Summer 2023.

Conclusions

This study will explain implementation process and outcomes using a multifaceted implementation strategy for a healthy lifestyle-promoting practice in a real-world PHC context. The study is expected to provide new knowledge about the role of facilitators and their contribution to implementation outcomes. These findings can guide policy makers, managers, and PHC staff to integrate health promotion and disease prevention in PHC and provide methodological support to facilitators.

Trial Registration

ClinicalTrials.gov NCT04799860; https://clinicaltrials.gov/ct2/show/NCT04799860

International Registered Report Identifier (IRRID)

DERR1-10.2196/37634

Self-compassion and professional quality of life among midwives and nurse assistants: A cross-sectional study

INTRODUCTION

Self-compassion and satisfaction derived from helping others is part of healthcare providers’ professional quality of life. The aim of this study was to explore and psychometrically test two instruments measuring self-compassion and professional quality of life among midwives and nurse assistants.

METHODS

This was a cross-sectional study with midwives and nurse assistants working with intrapartum care at five different labor wards in Sweden. The Self-Compassion Scale (SCS) and the modified Professional Quality of Life Measurement (ProQOL) were validated and correlation analyses were calculated between the different subscales. Descriptive statistics, t-test, were calculated to analyze associations between the subscales of the SCS, the ProQOL and the background variables.

RESULTS

Midwives were more self-critical than nurse assistants, and the midwives who were negative towards the new clinical practice scored higher for compassion fatigue. The principal component analysis showed a two-factor solution for both the SCS and the modified ProQOL. The two SCS subscales were named ‘self-criticism’ (α=0.85) and ‘self-kindness’ (α=0.87). The two ProQOL subscales were named ‘compassion satisfaction’ (α=0.83) and ‘compassion fatigue’ (α=0.78). A negative correlation was found between self-kindness and compassion fatigue subscales, between compassion satisfaction and compassion fatigue, and between self-kindness and self-criticism.

CONCLUSIONS

The SCS and modified ProQOL are considered as valid questionnaires for use in a Swedish maternity setting and a correlation between the scales was found. Midwives are more self-critical than nurse assistants. Understanding and identifying compassion fatigue among midwives is important to managers responsible for quality improvement and practice changes.

The Utility of an Online Forward Triage Tool During the SARS-CoV-2 Pandemic: Health Care Provider and Health Authority Perspectives

Introduction

The SARS CoV-2 pandemic poses major challenges not only to patients but also to health care professionals and policy-makers, with rapidly changing, sometimes complex, recommendations, and guidelines to the population. Online forward triage tools (OFTT) got a major boost from the pandemic as they helped with the implementation and monitoring of recommendations.

Methods

A multiphase mixed method sequential explanatory study design was employed. Quantitative data were collected first and informed the qualitative interview guides. Video interviews were held with key informants (health care providers and health authorities) between 2 September and 10 December 2020. Audio-recordings were transcribed verbatim, coded thematically and compared with patient perspectives (framework).

Objectives

To explore the perspectives of health care providers and authorities in Canton Bern on the utility of a COVID-19 OFTT, as well as elicit recommendations for telehealth in future.

Results

The following themes emerged; (i) accessibility (ii) health system burden reduction (iii) utility in preventing onward transmission (iv) utility in allaying fear and anxiety (v) medical decision-making utility (vi) utility as information source (vii) utility in planning and systems thinking. The health care providers and health authorities further provided insights on potential barriers and facilitators of telehealth in future.

Conclusion

Similar to patients, health care providers acknowledge the potential and utility of the COVID-19 OFTT particularly as an information source and in reducing the health system burden. Data privacy, doctor-patient relationship, resistance to change, regulatory, and mandate issues, and lack of systems thinking were revealed as barriers to COVID-19 OFTT utility.

Challenges to implementing artificial intelligence in healthcare: a qualitative interview study with healthcare leaders in Sweden

BACKGROUND

Artificial intelligence (AI) for healthcare presents potential solutions to some of the challenges faced by health systems around the world. However, it is well established in implementation and innovation research that novel technologies are often resisted by healthcare leaders, which contributes to their slow and variable uptake. Although research on various stakeholders' perspectives on AI implementation has been undertaken, very few studies have investigated leaders' perspectives on the issue of AI implementation in healthcare. It is essential to understand the perspectives of healthcare leaders, because they have a key role in the implementation process of new technologies in healthcare. The aim of this study was to explore challenges perceived by leaders in a regional Swedish healthcare setting concerning the implementation of AI in healthcare.

METHODS

The study takes an explorative qualitative approach. Individual, semi-structured interviews were conducted from October 2020 to May 2021 with 26 healthcare leaders. The analysis was performed using qualitative content analysis, with an inductive approach.

RESULTS

The analysis yielded three categories, representing three types of challenge perceived to be linked with the implementation of AI in healthcare: 1) Conditions external to the healthcare system; 2) Capacity for strategic change management; 3) Transformation of healthcare professions and healthcare practice.

CONCLUSIONS

In conclusion, healthcare leaders highlighted several implementation challenges in relation to AI within and beyond the healthcare system in general and their organisations in particular. The challenges comprised conditions external to the healthcare system, internal capacity for strategic change management, along with transformation of healthcare professions and healthcare practice. The results point to the need to develop implementation strategies across healthcare organisations to address challenges to AI-specific capacity building. Laws and policies are needed to regulate the design and execution of effective AI implementation strategies. There is a need to invest time and resources in implementation processes, with collaboration across healthcare, county councils, and industry partnerships.

Organizational readiness to implement the Serious Illness Care Program in hospital settings in Sweden

BACKGROUND

The Serious Illness Care Program (SICP) is a model developed for structured communication, identifying patients, and training physicians to use a structured guide for conversations with patients and family members. However, there is a lack of knowledge regarding the sustainable implementation of this conversation model. Therefore, the aim of this study was to identify barriers and enablers during the implementation of the SICP in hospital settings.

METHODS

The SICP was implemented at 20 units in two hospitals in Sweden. During the implementation process, seven individual interviews and two group interviews were conducted with seven facilitators (five physicians, one behavioral therapist, and one administrator). Data were analyzed using qualitative content analysis, first inductively, and then deductively using the organizational readiness for change as a theoretical framework.

RESULT

The analysis resulted in three factors acting as enablers and eight factors acting as enablers and/or barriers during the implementation of the SICP. The three factors considered as enablers were preliminaries, identifying patients, and facilitator's role. The eight factors considered as enablers and/or barriers were broad implementation, leadership, time, confidence, building foundation, motivation to work change, motivation for training in serious illness conversations, and attitudes.

CONCLUSION

This study indicates limited readiness to implement the SICP in hospital settings due to considerable variation in organizational contextual factors, change efficacy, and change commitment. The identified enablers and barriers for implementation of the SICP could guide and support future implementations to be sustainable over time.

Implementing a new emergency department: a qualitative study of health professionals' change responses and perceptions

Background

The aim of the study is two-fold. It explores how managers and key employees at the Emergency Department (ED) and specialist departments in a university hospital in the Capital Region of Denmark respond to the planned change to a new ED, and how they perceive the change involved in the implementation of the new ED. The study investigates what happens when health professionals are confronted with implementation of policy that changes their organization and everyday work lives. Few studies provide in-depth investigations of health professionals’ reactions to the implementation of new EDs, and particularly how they influence the implementation of a nationwide organizational change framed within a political strategy.

Methods

The study used semi-structured individual interviews with 51 health professionals involved in implementation activities related to an organizational change of establishing a new ED with new patient pathways for acutely ill patients. The data was deductively analyzed using Leon Coetsee’s theoretical framework of change responses, but the analysis also allowed for a more inductive reading of the material.

Results

Fourteen types of responses to establishing a new ED were identified and mapped onto six of the seven overall change responses in Coetsee’s framework. The participants perceived the change as particularly three changes. Firstly, they wished to create the best possible acute patient pathway in relation to their specialty. Whether the planned new ED would redeem this was disputed. Secondly, participants perceived the change as relocation to a new building, which both posed potentials and worries. Thirdly, both hopeful and frustrated statements were given about the newly established medical specialty of emergency medicine (EM), which was connected to the success of the new ED.

Conclusions

The study showcases how implementation processes within health care are not straightforward and that it is not only the content of the implementation that determines the success of the implementation and its outcomes but also how these are perceived by managers and employees responsible for the process and their context. In this way, managers must recognize that it cannot be pre-determined how implementation will proceed, which necessitates fluid implementation plans and demands implementation managements skills.

ICD-11 Morbidity Pilot in Kuwait: Methodology and Lessons Learned for Future Implementation

This paper reports on the first ICD-11 morbidity pilot for inpatient discharges in a public general hospital. We detail the pilot methodology, lessons learned in terms of facilitators and challenges, physician-reported opinion, and considerations for future implementation. The pilot included: engaging stakeholders; selecting the setting; building a common understanding of the discharge process; evaluating and preparing IT infrastructure; ICD-11 training; small-scale pre-pilot testing; implementing the pilot while providing on-site support and collecting data for analysis including a brief user-experience survey. Overall, physicians were satisfied with the experience. Facilitators for success included national health system influence, leadership commitment, a multidisciplinary team approach, physician-tailored training, using social media for training, and providing on-site support. Challenges included potential IT problems, and difficulties relating to training and engaging physicians. Issues to consider include DRG system requirements, and comparability of ICD-11 pilot results from different countries. In conclusion, ICD-11 can be successfully implemented for documenting diagnoses by physicians in a public hospital by installing the coding tool on the electronic hospital information system. Pilots can improve ICD-11 content by using the online proposal mechanism. Implementing ICD-11 requires effective change management, stakeholder-tailored communication, and innovative ideas for training to match the electronic nature of ICD-11 and its potential new users, physicians.

Exploring the implementation of evidence-based optimisation strategies: A qualitative study of the experience of diagnostic radiographers

INTRODUCTION

Radiographers are responsible for ensuring safe and effective use of ionising radiation. Through evidence-based practice (EBP), valuable optimisation strategies can be implemented to fulfil these responsibilities. This study aimed to explore radiographers' attitudes, perceptions, and experience of using evidence-based optimisation strategies.

METHODS

A Grounded Theory approach using in-depth interviews. UK-based radiographers were recruited. Discussions focused on (1) the role of evidence-based optimisation strategies in daily practice, (2) assistance in implementing evidence-based optimisation strategies, and (3) the role of EBP and optimisation strategies in the future. Interviews were transcribed verbatim and analysed using open and axial coding.

RESULTS

Participants (n = 13) stated that EBP is not frequently used to implement optimisation strategies. Participants relied on the knowledge taught in education settings and their professional skills to optimise in daily practice, alongside departmental protocols. Barriers identified as affecting the implementation of optimisation strategies related to reluctance to change, a lack of support from superiors, and a lack of resources to engage with EBP. Some participants expected the use of optimisation strategies to become unnecessary due to technology advancements.

CONCLUSION

The results indicate that effective operationalisation of EBP is not part of daily practice among radiographers to implement valuable optimisation strategies in daily practice.

IMPLICATIONS FOR PRACTICE

The potential barriers to implementing evidence-based optimisation strategies highlighted in this study suggest that improving access to resources and empowerment of individual radiographers is required to enable radiographers to implement optimisation strategies.

Physiotherapists' experiences of osteoarthritis guidelines in primary health care - an interview study

BACKGROUND

Osteoarthritis is a common joint disease, globally. Guidelines recommend information, exercise and, if needed, weight reduction as core treatment. There is a gap between evidence-based recommended care for osteoarthritis and clinical practice. To increase compliance to guidelines, implementation was conducted. The aim of the study was to explore physiotherapists' experiences of osteoarthritis guidelines and their experiences of implementation of the guidelines in primary health care in a region in southern Sweden.

METHODS

Eighteen individual, semi-structured interviews with physiotherapists in primary health care were analysed with inductive qualitative content analysis.

RESULTS

The analysis resulted in two categories and four subcategories. The physiotherapists were confident in their role as primary assessors for patients with osteoarthritis and the guidelines were aligned with their professional beliefs. The Supported Osteoarthritis Self-Management Programme, that is part of the guidelines, was found to be efficient for the patients. Even though the physiotherapists followed the guidelines they saw room for improvement since all patients with hip and/or knee osteoarthritis did not receive treatment according to the guidelines. Furthermore, the physiotherapists emphasised the need for management's support and that guidelines should be easy to follow.

CONCLUSION

The physiotherapists believed in the guidelines and were confident in providing first line treatment to patients with osteoarthritis. However, information about the guidelines probably needs to be repeated to all health care providers and management. Data from a national quality register on osteoarthritis could be used to a greater extent in daily clinical work in primary health care to improve quality of care for patients with osteoarthritis.

The impact of implementing a person-centred pain management intervention on resistance to change and organizational culture

BACKGROUND

Resistance to change and organizational culture are essential factors to consider in change management in health care settings. Implementation of structural change remains a challenge. There is a lack of studies providing information on the impact of implementation processes on the organization. The aim of this study was to describe the impact of implementing a systematic change process concerning postoperative person-centred pain management on resistance to change and organizational culture in an orthopaedic spine surgery unit.

METHODS

The study was set in an orthopaedic spine surgery unit at a university hospital. Person-centred bundles of care for postoperative pain management of spine surgery patients were developed in co-creation by a multi-professional expert group and implemented throughout the care pathway. The intervention was underpinned by theories on organizational culture and inspired by principles of person-centred care. Quantitative data were collected using the Resistance to Change Scale and the Organizational Culture Assessment Instrument and analysed using descriptive statistics.

RESULTS

The findings showed a low resistance to change decreasing during the study. The organizational culture shifted from a result-oriented to a formalized and structured culture after the implementation. The culture preferred by the staff was team-oriented and participation-focused throughout the study. The discrepancy between the current and preferred cultures remained extensive over time.

CONCLUSION

It is challenging to describe the influence of the development and implementation of a postoperative pain management program on organizational culture as well as in terms of resistance to change, in a complex health care setting. In the current study the unit was under organizational strain during the implementation. Albeit, the important discrepancy between the current and preferred organizational culture could imply that structural changes aren't enough when implementing person-centred pain management structures and needs to be combined with relational aspects of change.

Centralisation of acute obstetric care in the Netherlands: a qualitative study to explore the experiences of stakeholders with adaptations in organisation of care

Background

In the past decade, acute obstetric care (AOC) has become centralised in many high-income countries. In this qualitative study, we explored how stakeholders in maternity care perceived and experienced adaptations in the organisation of maternity care in areas in the Netherlands where AOC was centralised.

Methods

A heterogenic group of fifteen maternity care stakeholders, including patients, were purposively selected for semi-structured interviews. An inductive thematic analysis was used.

Results

Three main themes were identified: (1) lack of involvement. (2) the process of making adaptations in the organisation of maternity care. (3) maintaining quality of care. Stakeholders in this study were highly motivated to maintain a high quality of maternity care and therefore made adaptations at several organisational levels. However, they felt a lack of involvement during the planning of centralisation of AOC and highlighted the importance of a collaborative process when making adaptations after centralisation of AOC.

Conclusions

Regions with AOC centralisation plans should invest time and money in change management, encourage early involvement of all maternity care stakeholders and acknowledge centralisation of AOC as a professional life event with associated emotions, including a feeling of unsafety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07269-4.

Organizing work in local service implementation: an ethnographic study of nurses' contributions and competencies in implementing a municipal acute ward

BACKGROUND

The increased prevalence of chronic diseases and an ageing population challenge healthcare delivery, particularly hospital-based care. To address this issue, health policy aims to decentralize healthcare by transferring responsibility and introducing new services in primary healthcare. In-depth knowledge of associated implementation processes is crucial for health care managers, policymakers, and the health care personnel involved. In this article, we apply an ethnographic approach in a study of nurses' contributions to the implementation of a new inpatient service in an outpatient primary care emergency clinic and explore the competencies involved. The approach allowed us to explore the unexpressed yet significant effort, knowledge and competence of nurses that shaped the new service.

METHODS

The study combines observations (250 h) and several in situ interviews with healthcare personnel and individual in-depth interviews with nurses (n = 8) at the emergency clinic. In our analysis, we draw on a sociological perspective on healthcare work and organization that considers nursing a practice within the boundaries of clinical patient work, organizational structures, and managerial and professional requirements.

RESULTS

We describe the following three aspects of nurses' contributions to the implementation of the new service: (1) anticipating worst-case scenarios and taking responsibility for preventing them, (2) contributing coherence in patient care by ensuring that new and established procedures are interconnected, and (3) engaging in "invisible work". The nurses draw on their own experiences from their work as emergency nurses and knowledge of the local and regional contexts. They utilize their knowledge, competence, and organizing skills to influence the implementation process and ensure high-quality healthcare delivery in the extended service.

CONCLUSIONS

Our study illustrates that nurses' contributions are vital to coordinating and adjusting extended services. Organizing work, in addition to clinical work, is a crucial aspect of nursing work. It 'glues' the complex and varied components of the individual patient's services into coherent and holistic care trajectories. It is this organizing competence that nurses utilize when coordinating and adjusting extended services. We believe that nurses' organizing work is generally invaluable in implementing new services, although it has not been well emphasized in practice and research.

Operationalising outpatient antimicrobial stewardship to reduce system-wide antibiotics for acute bronchitis

BACKGROUND

Antibiotics are not recommended for treatment of acute uncomplicated bronchitis (AUB), but are often prescribed (85% of AUB visits within the Veterans Affairs nationally). This quality improvement project aimed to decrease antibiotic prescribing for AUB in community-based outpatient centres from 65% to <32% by April 2020.

METHODS

From January to December 2018, community-based outpatient clinics' 6 months' average of prescribed antibiotics for AUB and upper respiratory infections was 63% (667 of 1054) and 64.6% (314 of 486) when reviewing the last 6 months. Seven plan-do-study-act (PDSA) cycles were implemented by an interprofessional antimicrobial stewardship team between January 2019 and March 2020. Balancing measures were a return patient phone call or visit within 4 weeks for the same complaint. Χ² tests and statistical process control charts using Western Electric rules were used to analyse intervention data.

RESULTS

The AUB antibiotic prescribing rate decreased from 64.6% (314 of 486) in the 6 months prior to the intervention to 36.8% (154 of 418) in the final 6 months of the intervention. No change was seen in balancing measures. The largest reduction in antibiotic prescribing was seen after implementation of PDSA 6 in which 14 high prescribers were identified and targeted for individualised reviews of encounters of patients with AUB with an antimicrobial steward.

CONCLUSIONS

Operational implementation of successful stewardship interventions is challenging and differs from the traditional implementation study environment. As a nascent outpatient stewardship programme with limited resources and no additional intervention funding, we successfully reduced antibiotic prescribing from 64.6% to 36.8%, a reduction of 43% from baseline. The most success was seen with targeted education of high prescribers.

Continuous flow insufflation of oxygen compared with manual ventilation during out-of-hospital cardiac arrest: A survey of the paramedics

Introduction:

In 2018, a continuous flow insufflation of oxygen (CFIO) device (b-card™, Vygon (USA)) placed on a supraglottic airway (SGA) became the standard of care to ventilate patients during adult out-of-hospital cardiac arrest (OHCA) care in Quebec–Capitale-Nationale region, Canada. This study aims to assess the paramedics’ perception as well as the disadvantages and the benefits relative to the use of CFIO during OHCA management.

Methods:

An invitation to complete an online survey (Survey Monkey™) was sent to all 560 paramedics who are working in our region. The survey included 22 questions of which 9 aimed to compare the traditional manual ventilation with a bag to the CFIO using a 5-point Likert-type scale.

Results:

A total of 244 paramedics completed the survey, of which 189 (77.5%) had used the CFIO device during an OHCA at least once. Most respondents felt that the intervention was faster (70.2%) and easier (86.5%) with the CFIO device compared with manual ventilation. CFIO was also associated with perceived increased patient safety (64.4%) as well as paramedic safety during the evacuation (88.9%) and the ambulance transport (88.9%). Paramedics reported that physical (48.1%) and cognitive (52.9%) fatigue were also improved with CFIO. The main reported barriers were the bending of the external SGA tube and the loss of capnography values.

Conclusion:

The use of CFIO during adult OHCA care allows a simplified approach and was perceived as safer for the patient and the paramedics compared with manual ventilation. Its impact on patient-centred outcomes needs to be assessed.

The RELATE model: strategies to effectively engage healthcare organisations to create amenable contexts for implementation

PURPOSE

The field of implementation science has emerged as a response to the challenges experienced in translating evidence-based practice and research findings to healthcare settings. Whilst the field has grown considerably in recent years, comparatively, there is a conspicuous lack of attention paid to the work of pre-implementation, that is, how we effectively engage with organisations to support the translation of research into practice. Securing the engagement and commitment of healthcare organisations and staff is key in quality improvement and organisational research. In this paper the authors draw attention to the pre-implementation phase, that is, the development of an amenable context to support implementation research.

DESIGN/METHODOLOGY/APPROACH

Drawing from examples across an interdisciplinary group of health systems researchers working across a range of healthcare organisations, the authors present a reflective narrative viewpoint. They identify the principal challenges experienced during the course of their work, describe strategies deployed to effectively mitigate these challenges and offer a series of recommendations to researchers based on their collective experiences of engaging in collaborations with healthcare organisations for research and implementation. This reflective piece will contribute to the narrative evidence base by documenting the challenges, experiences and learning emerging from the authors' work as university researchers seeking to engage and collaborate with healthcare organisations.

FINDINGS

The RELATE model is presented to guide researchers through six key steps and sample strategies in working to secure organisational buy-in and creating a context amenable to implementation and research. The six stages of the RELATE model are: (1) Recognising and navigating the organisation's complexity; (2) Enhancing understanding of organisational priorities and aligning intervention; (3) Leveraging common values and communicating to key individuals the value of implementation research; (4) Aligning and positioning intervention to illustrate synergies with other initiatives; (5) Building and maintaining credibility and trust in the research team; and (6) Evolving the intervention through listening and learning.

RESEARCH LIMITATIONS/IMPLICATIONS

The authors hope this guidance will stimulate thinking and planning and indeed that it will encourage other research teams to reflect and share their experiences and strategies for successful engagement of organisations, thus developing a knowledge base to strengthen implementation efforts and increase efficacy in this important enterprise.

ORIGINALITY/VALUE

Researchers must relate to the world's everyday reality of the healthcare managers and administrators and enable them to relate to the potential of the research world in enhancing practice if we are to succeed in bringing the evidence to practice in a timely and efficient manner. Climates receptive to implementation must be developed incrementally over time and require actors to navigate messy and potentially unfamiliar organisational contexts. In this paper, the often invisible and lamentably underreported work of how we begin to work with healthcare organisations has been addressed. The authors hope this guidance will stimulate thinking and planning and indeed that it will encourage other research teams to reflect and share their experiences and strategies for successful engagement of organisations, thus developing a knowledge base to strengthen implementation efforts and increase efficacy in this important enterprise.

Navigating change - managers' experience of implementation processes in disability health care: a qualitative study

Background

Effective implementation processes play a central role in health care organizations and affect the care of patients. Managers are pivotal in facilitating the use of new practices, but their experience and how it affects the implementation outcome are still largely unknown. In the field of disability health care in particular, managers experiences have scarcely been investigated. Therefore, the aim of this study is to explore managers’ experiences of the implementation process when transferring new practices into disability health care settings.

Methods

Semi-structured individual telephone interviews were conducted with managers at disability health care organizations in four administrative regions in central Sweden. A total of 23 managers with formal managerial responsibility from both public and private health care were strategically selected to be interviewed. The interviews were analysed using reflexive thematic analysis with an inductive approach.

Results

The analysis resulted in two themes about factors influencing the implementation process: firstly, Contextual factors set the agenda for what can be achieved, which highlighted aspects that hinder or enable the implementation process, such as internal and external conditions, the workplace culture, the employees and managers’ attitudes and openness to change: secondly, Leadership in the winds of change, which described the challenges of balancing managerial tasks with leading the change, and the importance of a leadership that involves the participation of the employees.

Conclusions

This study explored how and to what extent managers address and manage the implementation process and the many associated challenges. The findings highlight the importance of leadership support and organizational structure in order to transfer new practices into the work setting, and to encourage an organizational culture for leading change that promotes positive outcomes. We suggest that identifying strategies by focusing on contextual factors and on aspects of leadership will facilitate implementation processes.

Trial registration

The SWAN (Structured Water Dance Intervention) study was retrospectively registered on April 9, 2019 and is available online at ClinicalTrials.gov (ID: NCT03908801).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06570-6.

Using organization theory to position middle-level managers as agents of evidence-based practice implementation

Middle-level managers (MLMs; i.e., healthcare professionals who may fill roles including obtaining and diffusing information, adapting information and the intervention, mediating between strategy and day-to-day activities, and selling intervention implementation) have been identified as having significant influence on evidence-based practice (EBP) implementation. We argue that understanding whether and how MLMs influence EBP implementation is aided by drawing upon organization theory. Organization theories propose strategies for increasing MLMs' opportunities to facilitate implementation by optimizing their appreciation of constructs which we argue have heretofore been treated separately to the detriment of understanding and facilitating implementation: EBPs, context, and implementation strategies. Specifically, organization theory encourages us to delineate different types of MLMs and consider how generalist and hybrid MLMs make different contributions to EBP implementation. Organization theories also suggest that MLMs' understanding of context allows them to adapt EBPs to promote implementation and effectiveness; MLMs' potential vertical linking pin role may be supported by increasing MLMs' interactions with external environment, helping them to understand strategic pressures and opportunities; and how lateral connections among MLMs have the potential to optimize their contribution to EBP implementation as a collective force. We end with recommendations for practice and future research.

Establishing a Virtual Clinic for Developmental Dysplasia of the Hip: A Prospective Study

BACKGROUND

The aim was to describe the introduction and operation of a virtual developmental dysplasia of the hip (DDH) clinic. Our secondary objectives were to provide an overview of DDH referral reasons, treatment outcomes, and adverse events associated with it.

METHODS

A prospective observational study involving all patients referred to the virtual DDH clinic was conducted. The clinic consultant delivered with 2 DDH clinical nurse specialists (CNS). The outcomes following virtual review include further virtual review, CNS review, consultant review or discharge. Treatment options include surveillance, brace therapy, or surgery. Efficiency and cost analysis were assessed.

RESULTS

Over the 3.5-year study period, 1002 patients were reviewed, of which 743 (74.2%) were female. The median age at time of referral was 7 months, (interquartile range of 5 to 11) with a median time to treatment decision of 9 days. Median waiting times from referral to treatment decision was reduced by over 70%. There were 639 virtual reviews, 186 CNS reviews, and 144 consultant reviews. The direct discharge rate was 24%. One hundred one patients (10%) had dislocated or subluxed hips at initial visit while 26.3% had radiographically normal hips. Over the study period 704 face to face (F2F) visits were avoided. Cost reductions of €170 were achieved per patient, with €588,804 achieved in total. Eighteen parents (1.8%) opted for F2F instead of virtual review. There were no unscheduled rereferrals or recorded adverse events.

CONCLUSION

We report the outcomes of the first prospective virtual DDH clinic. This clinic has demonstrated efficiency and cost-effectiveness, without reported adverse outcomes to date. It is an option to provide consultant delivered DDH care, while reducing F2F consults.

LEVEL OF EVIDENCE

Level III.

Context counts: a qualitative study exploring the interplay between context and implementation success

PURPOSE

Implementing change in healthcare is difficult to accomplish due to the unpredictability associated with challenging the status quo. Adapting the intervention/practice/program being implemented to better fit the complex context is an important aspect of implementation success. Despite the acknowledged influence of context, the concept continues to receive insufficient attention at the team-level within implementation research. Using two heterogeneous multidisciplinary healthcare teams as implementation case studies, this study evaluates the interplay between context and implementation and highlights the ways in which context influences the introduction of a collective leadership intervention in routine practice.

DESIGN/METHODOLOGY/APPROACH

The multiple case study design adopted, employed a triangulation of qualitative research methods which involved observation (Case A = 16 h, Case B = 15 h) and interview data (Case A = 13 participants, Case B = 12 participants). Using an inductive approach, an in-depth thematic analysis of the data outlined the relationship between team-level contextual factors and implementation success.

FINDINGS

Themes are presented under the headings: (1) adapting to the everyday realities, a key determinant for implementation success and (2) implementation stimulating change in context. The findings demonstrate a dynamic relationship between context and implementation. The challenges of engaging busy healthcare professionals emphasised that mapping the contextual complexity of a site and adapting implementation accordingly is essential to enhance the likelihood of successful implementation. However, implementation also altered the surrounding context, stimulating changes within both teams.

ORIGINALITY/VALUE

By exposing the reciprocal relationship between team-level contextual factors and implementation, this research supports the improved design of implementation strategies through better understanding the interplay and mutual evolution of evidence-based healthcare interventions within different contexts.

The micropolitics of implementation; a qualitative study exploring the impact of power, authority, and influence when implementing change in healthcare teams

Background

Healthcare organisations are complex social entities, comprising of multiple stakeholders with differing priorities, roles, and expectations about how care should be delivered. To reach agreement among these diverse interest groups and achieve safe, cost-effective patient care, healthcare staff must navigate the micropolitical context of the health service. Micropolitics in this study refers to the use of power, authority, and influence to affect team goals, vision, and decision-making processes. Although these concepts are influential when cultivating change, there is a dearth of literature examining the mechanisms through which micropolitics influences implementation processes among teams. This paper addresses this gap by exploring the role of power, authority, and influence when implementing a collective leadership intervention in two multidisciplinary healthcare teams.

Methods

The multiple case study design adopted employed a triangulation of qualitative research methods. Over thirty hours of observations (Case A = 16, Case B = 15) and twenty-five interviews (Case A = 13, Case B = 12) were completed. An in-depth thematic analysis of the data using an inductive coding approach was completed to understand the mechanisms through which contextual factors influenced implementation success. A context coding framework was also employed throughout implementation to succinctly collate the data into a visual display and to provide a high-level overview of implementation effect (i.e. the positive, neutral, or negative impact of contextual determinants on implementation).

Results

The findings emphasised that implementing change in healthcare teams is an inherently political process influenced by prevailing power structures. Two key themes were generated which revealed the dynamic role of these concepts throughout implementation: 1) Exerting hierarchical influence for implementation; and 2) Traditional power structures constraining implementation. Gaining support across multiple levels of leadership was influential to implementation success as the influence exercised by these individuals persuaded follower engagement. However, the historical dynamics of each team determined how this influence was exerted and perceived, which negatively impacted some participants’ experiences of the implementation process.

Conclusion

To date, micropolitics has received scant attention in implementation science literature. This study introduces the micropolitical concepts of power, authority and influence as essential contextual determinants and outlines the mechanisms through which these concepts influence implementation processes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05905-z.

Caring Behavior Coding Scheme based on Swanson's Theory of Caring - development and testing among undergraduate nursing students

Rationale

To maintain patients’ dignity and well‐being and alleviate suffering, it is essential that healthcare providers engage in caring behaviours. Yet, every year patient boards receive an increasing number of complaints from patients and significant others regarding healthcare providers’ non‐caring behaviours. Defining and measuring both verbal and nonverbal caring and non‐caring behaviour in healthcare delivery is vital to address such complaints. However, no studies were found that incorporated a comprehensive theory of caring to code encounters between healthcare providers and patients.

Aim

The aim was to develop and test a Caring Behavior Coding Scheme based on Swanson’s Theory of Caring.

Method

An instrument development process was used for behavioural coding including observational data from thirty‐eight video recordings collected in an undergraduate nursing course at a Swedish University. The observational data involved interactions between undergraduate nursing students and a standardised patient.

Result

The Caring Behavior Coding Scheme (the CBCS), contains seventeen verbal and eight nonverbal behavioural codes, categorised as caring and non‐caring in accordance with Swanson’s Theory of Caring. Content and face validity were assessed. Timed‐event sequential continuous coding was performed in INTERACT software. The coder achieved excellent agreement with the developed gold standard (k = 0.87) and excellent mean inter‐rater reliability (k = 0.82). All domains in Swanson’s Theory of Caring were observed and coded in the interaction.

Discussion/Conclusion

The CBCS is a theory‐based instrument that contributes to research on healthcare providers’ behavioural encounters. It uses verbal and nonverbal caring and non‐caring behavioural codes to assess the alignment of both the theory and practice of caring. The CBCS can contribute to both development and measurement of interventions focused on improving healthcare providers’ caring behaviour with the intended outcome of patient well‐being.