The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

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.

SNAP: Supportive non-invasive ventilation for acute chest syndrome prevention for hospitalized children with sickle cell disease: Perspectives of patients, parents, and the healthcare team

RATIONALE

Acute chest syndrome (ACS) often develops during hospitalizations for sickle cell disease (SCD) vaso-occlusive episodes and may be triggered by a combination of chest wall splinting, opioid use, hypoventilation, and atelectasis. In 2017, Boston Medical Center's general pediatric inpatient unit instituted the novel use of bi-level positive airway pressure (BiPAP) as "supportive non-invasive ventilation for ACS prevention" (SNAP) to prevent ACS and respiratory decompensation.

OBJECTIVE

The goals of this qualitative study were to identify perceived benefits, harms, facilitators, and barriers to use of SNAP.

METHODS

We conducted semi-structured key informant interviews at three sites with different levels of SNAP implementation (Site 1: extensive implementation; Site 2: limited implementation; Site 3: not yet implemented) regarding experiences with and/or perceptions of SNAP. Interviews and coding were guided by the Promoting Action on Research Implementation in Health Services (PARiHS) framework.

RESULTS

Thirty-four participants (physicians, nurses, respiratory therapists, child life specialists, psychologists, youth with SCD, and parents) completed interviews. Major themes included: (i) participants perceive BiPAP as effective at preventing ACS, and for those with medically stable ACS, for preventing respiratory decompensation. (ii) BiPAP use is appropriate on the general pediatric inpatient unit for medically stable patients with SCD. (iii) Improving the patient experience is the most important factor to optimize acceptance of BiPAP by patients and families.

CONCLUSION/FUTURE DIRECTIONS

SNAP is perceived as effective and appropriate for hospitalized pediatric patients with SCD. Improving the patient experience is the biggest challenge. These data will inform a future protocol for a multicenter hybrid effectiveness/implementation trial of SNAP.

Diverting Food Waste From Landfill in Exemplar Hospital Foodservices: A Qualitative Study

BACKGROUND

The US Environmental Protection Agency Food Recovery Hierarchy suggests methods for diverting food waste from landfill. Knowledge of how hospital foodservices implement food waste management strategies could help modernize food waste practices.

OBJECTIVE

The aim of this study was to explore hospital staff members' experiences of implementing a food waste management strategy to divert food waste from landfill in their hospital foodservice, including the journey, challenges, and facilitators of this practice change.

DESIGN

A qualitative study was conducted in 2022-2023 using semi-structured interviews.

PARTICIPANTS/SETTING

Eighteen participants were staff members with knowledge of the food waste management strategy from 14 exemplar hospitals in United States, Spain, Scotland, and Australia using strategies to divert food waste from landfill within the last 10 years.

ANALYSES PERFORMED

Mapping and thematic analysis were undertaken to code and identify themes from the interviews that described staff members' experiences of the journey to implement the strategy.

RESULTS

Six hospitals donated food, 1 transferred food waste for animal feed, 4 used an industrial solution, and 3 sent food waste for composting. A common journey pathway for successful implementation was identified from participants' experiences. It features the following 6 phases: idea, preparation, roll out, maintenance, established practice, and evolution. Facilitators included legislation, enthusiastic staff members, executive support, and "luck." Challenges were smells, occasions when food waste was not collected, equipment breakage, and funding depletion.

CONCLUSIONS

This study identified a common journey pathway for implementing a food waste management strategy in hospital foodservices that can be used to anticipate and prepare for the steps in the implementation process.

Using implementation science to operate as a learning health system to improve outcomes in early psychosis

AIM

Early interventions are well understood to improve psychosis outcomes, but their successful implementation remains limited. This article introduces a three-step roadmap for advancing the implementation of evidence-based practices to operate as a learning health system, which can be applied to early interventions for psychosis and is intended for an audience that is relatively new to systematic approaches to implementation.

METHODS

The roadmap is grounded in implementation science, which specializes in methods to promote routine use of evidence-based innovations. The roadmap draws on learning health system principles that call for commitment of leadership, application of evidence, examination of care experiences, and study of health outcomes. Examples are discussed for each roadmap step, emphasizing both data- and stakeholder-related considerations applicable throughout the roadmap.

CONCLUSIONS

Early psychosis care is a promising topic through which to discuss the critical need to move evidence into practice. Despite remarkable advances in early psychosis interventions, population-level impact of those interventions is yet to be realized. By providing an introduction to how implementation science principles can be operationalized in a learning health system and sharing examples from early psychosis care, this article prompts inclusion of a wider audience in essential discourse on the role that implementation science can play for moving evidence into practice for other realms of psychiatric care as well. To this end, the proposed roadmap can serve as a conceptual guiding template and framework through which various psychiatric services can methodically pursue timely implementation of evidence-based interventions for higher quality care and improved outcomes.

Feasibility and acceptability of a novel biomedical device to prevent neonatal hypothermia and augment Kangaroo Mother Care in Kenya: Qualitative analysis of focus group discussions and key Informant Interviews

Hypothermia is a leading newborn complication, especially among premature and/or low birth weight infants. Within low/middle-income countries where incubators and radiant warmers are often in short supply, leading to gaps in the thermal care chain, neonatal hypothermia underlies high rates of newborn morbidity and mortality. Kangaroo Mother Care/Skin-to-skin care is an effective method for prevention of hypothermia in premature and low birthweight babies but can be very burdensome for families and healthcare providers. Our international multidisciplinary team has developed a prototype for a wearable biomedical device ("NeoWarm") to provide continuous thermal care and augment kangaroo mother care practices in low-resource settings. The objective of this study was to assess the feasibility and acceptability of NeoWarm and to obtain user design feedback for an early prototype from among adult end-users in Western Kenya. We performed key informant interviews (n = 17) among healthcare providers and 5 focus group discussions (FGDs) among 3 groups of adult stakeholders of premature babies, including: (1) parents/family members of premature babies aged 6 weeks or less (3 FGDs); (2) healthcare providers of newborns (e.g., nurses; physicians; 1 FGD); (3) community opinion leaders and stakeholders (e.g., traditional birth attendants; pastors; village elders; 1 FGD). Content and thematic analyses of transcripts indicate that NeoWarm is acceptable and feasible in promoting facility-based kangaroo mother care in the Kenyan setting. Novel findings derived from respondents include (1) the ability of the device to potentially overcome several barriers to traditional kangaroo mother care methods and (2) user-driven encouragement to expand the use case of the device to potentially include community-based kangaroo mother care and neonatal transport. User design feedback obtained during the interviews informed several key design iterations for subsequent prototypes of the device.

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

BACKGROUND

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Patient navigation for pregnant individuals with opioid use disorder: Results of a randomized multi-site pilot trial

BACKGROUND AND AIMS

Patient navigation (PN) may benefit pregnant individuals with opioid use disorder (OUD) by improving treatment adherence. We examined participant enrollment, session delivery and assessment feasibility for a PN intervention among pregnant participants and compared PN preliminary effectiveness for OUD treatment engagement with participants in usual care (UC).

DESIGN

This study was a pilot single-blinded multi-site randomized trial.

SETTING

Two academic medical centers in Pennsylvania (n = 57) and Utah (n = 45), United States participated.

PARTICIPANTS

One hundred and two pregnant adult participants unestablished (fewer than 6 weeks) on medication for OUD (MOUD) were randomized to PN (n = 53) or UC (n = 49).

INTERVENTION

PN was composed of 10 prenatal sessions (delivered after baseline but before the prenatal assessments) and four postnatal sessions (delivered before the 2- and 6-month postpartum assessments) focused upon OUD treatment and physical/mental health needs. UC involved brief case management.

MEASUREMENTS

Feasibility assessments included consent, session delivery and assessment rates. Mixed-effect models for intent-to-treat (ITT) and per protocol (PP, received six or more sessions) populations were estimated to compare outcomes of MOUD use, secondary outcomes of substance use disorder (SUD) treatment attendance and non-prescribed opioid use, and exploratory outcome of overdose at baseline, predelivery and 2 and 6 months postpartum.

FINDINGS

We consented 87% (106 of 122) of the proposed target, delivered ~60% of sessions delivered and completed ≥ 75% assessments. PN ITT and PP had better MOUD adherence, SUD treatment attendance, non-prescribed opioid use and overdose outcomes than UC. Notable changes included good evidence for greater percentage change in days for PN PP MOUD use from baseline to 2 months postpartum [PN = 28.0 versus UC = -10.9, 95% confidence interval (CI) = 9.7, 62.1] and some evidence for baseline to 6 months postpartum (PN = 45.4 versus UC = 23.4, 95% CI = -0.7, 48.2). PN PP percentage change in days for SUD treatment attendance also showed good evidence for improvements from baseline to prenatal assessment (PN = 7.4 versus UC = -21.3, 95% CI = 3.3, 53.5). PN compared to UC participants reported fewer overdoses at 2 months (PN = 11.9%/UC = 16.1%) and at 6 months postpartum (PN = 3.8%/UC = 6.2%).

CONCLUSIONS

Patient navigation appears to be associated with improvements in opioid use disorder treatment engagement and overdoses during pregnancy. This pilot trial shows the feasibility of the intervention and a future large-scale trial.

Relevance and use of health policy, health systems and health services research for strengthening rehabilitation in real-life settings: methodological considerations

Research on health policy, systems, and services (HPSSR) has seen significant growth in recent decades and received increasing attention in the field of rehabilitation. This growth is driven by the imperative to effectively address real-life challenges in complex healthcare settings. A recent resolution on 'Strengthening rehabilitation in health systems' adopted by the World Health Assembly emphasizes the need to support societal health goals related to rehabilitation, particularly to promote high-quality rehabilitation research, including HPSSR. This conceptual paper, discussed with the participants in the 5th Cochrane Rehabilitation Methodological Meeting held in Milan on September 2023, outlines study designs at diverse levels at which HPSSR studies can be conducted: the macro, meso, and micro levels. It categorizes research questions into four types: those framed from the perspective of policies, healthcare delivery organizations or systems, defined patient or provider populations, and important data sources or research methods. Illustrative examples of appropriate methodologies are provided for each type of research question, demonstrating the potential of HPSSR in shaping policies, improving healthcare delivery, and addressing patient and provider perspectives. The paper concludes by discussing the applicability, usefulness, and implementation of HPSSR findings, and the importance of knowledge translation strategies, drawing insights from implementation science. The goal is to facilitate the integration of research findings into everyday clinical practice to bridge the gap between research and practice in rehabilitation.

Is this to be another project that fizzles out? Using the i-PARIHS framework to evaluate implementation of a mentoring programme

It is well-known that the implementation of evidence into clinical practice is complex and challenging. The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework conceptualizes successful implementation of evidence into practice. As the implementation of the mentoring programme proved to be a challenge, it seemed valuable to retrospectively study the implementation process using a framework like the i-PARIHS.

AIM

The aim of this study was to evaluate implementation of a multifaceted mentoring programme for bedside nurses using the i-PARIHS framework, to identify factors that influenced the implementation.

DESIGN

A secondary analysis of qualitative data using the i-PARIHS framework as the theoretical lens.

METHOD

A directed content analysis was performed, driven theoretically by the i-PARIHS framework. The analysis focused separately on (a) characteristics of the innovation and (b) successful and hindering factors in the implementation process.

RESULTS

The results showed that successful factors influencing implementation of the mentoring programme included supportive and actively involved formal leaders and supervisors at the unit level. A major hindering factor was lack of resources in the form of personnel, time and money. A lack of facilitators, particularly experienced facilitators, throughout the organization hindered implementation. The i-PARIHS framework offered a structured how-to guide to identify factors that influenced the implementation process.

CONCLUSION

Implementation of the mentoring programme was a challenge for the organization. Investment into implementation should continue, with a more structured facilitation process. A structured and prioritized management system, including supportive leadership at the unit level, should be established by the hospital board.

IMPLICATIONS FOR THE PROFESSION

There is a need for experienced facilitators throughout the organization. This is crucial to achieve sustainability in the mentoring programme and ensure that the large investments of staff resources and money do not fizzle out.

IMPACT

What problem did the study address? Implementing a mentoring programme for nurses in a large university hospital proved to be a challenge. Therefore, it seemed valuable to retrospectively study the implementation process using a framework like the i-PARIHS. What were the main findings? A lack of facilitators, particularly experienced facilitators, throughout the organization hindered the implementation. The i-PARIHS framework offered a structured how-to guide to identify factors that influenced the implementation process. Where and on whom will the research have an impact? Our findings are important for leaders on all levels in a hospital setting, including the hospital board, heads of departments and nurse managers.

REPORTING METHOD

Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups is used.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Developing a strategy to scale up place-based arts initiatives that support mental health and wellbeing: A realist evaluation of 'Arts for the Blues'

Place-based arts initiatives are regarded as rooted in local need and as having capacity to engage local assets. However, many place-based arts initiatives remain poorly funded and short-lived, receiving little attention on how to scale up and sustain their activities. In this study we make a unique contribution to knowledge about scaling up place-based arts initiatives that support mental health and wellbeing through focusing on the example of 'Arts for the Blues', an arts-based psychological group intervention designed to reduce depression and improve wellbeing amongst primary care mental health service users in deprived communities. Methodologically, we used realist evaluation to refine the study's theoretical assumptions about scaling up, drawing on the lived and professional experiences of 225 diverse stakeholders' and frontline staff through a series of focus groups and evaluation questions at two stakeholders' events and four training days. Based on our findings, we recommend that to scale up place-based arts initiatives which support mental health and wellbeing: (i) the initiative needs to be adaptable, clear, collaborative, evidence-based, personalised and transformative; (ii) the organisation has to have a relevant need, have an understanding of the arts, has to have resources, inspiration and commitment from staff members, relevant skillsets and help from outside the organisation; (iii) at a policy level it is important to pay attention to attitude shifts towards the arts, meet rules, guidelines and standards expected from services, highlight gaps in provision, seek out early intervention and treatment options, and consider service delivery changes. The presence of champions at a local level and buy-in from managers, local leaders and policy makers are also needed alongside actively seeking to implement arts initiatives in different settings across geographical spread. Our theoretically-based and experientially-refined study provides the first ever scaling up framework developed for place-based arts initiatives that support the mental health and wellbeing, offering opportunities for spread and adoption of such projects in different organisational contexts, locally, nationally and internationally.

Development of an Implementation Strategy Tailored to Deliver Evidence-Based and Person-Centred Nursing Care for Patients with Community-Acquired Pneumonia: An Intervention Mapping Approach

Community-acquired pneumonia is a serious public health problem, and more so in older patients, leading to high morbidity and mortality. However, this problem can be reduced by optimising in-hospital nursing care. Accordingly, this study describes a systematic process of designing and developing a tailored theory- and research-based implementation strategy that supports registered nurses (RNs) in delivering evidence-based and person-centred care for this patient population in a hospital setting. The implementation strategy was developed by completing the six steps of the Intervention Mapping framework: (1) developing a logic model of the problem and (2) a logic model of change by defining performance and change objectives, (3) designing implementation strategy interventions by selecting theory-based change methods, (4) planning the interventions and producing materials through a co-design approach, (5) developing a structured plan for adoption, maintenance and implementation and (6) developing an evaluation plan. This method can serve as a guide to (1) target behavioural and environmental barriers hindering the delivery of nursing care in local clinical practice, (2) support evidence uptake, (3) support RNs in the delivery of nursing care according to individual patient needs and thereby (4) optimise health-related patient outcomes.

"Meeting Patients Where They're at": Clinician Perspectives on Integration of Family Planning Services into Office-Based Addiction Treatment

OBJECTIVES

To study clinician perspectives on the feasibility of incorporating family planning services within office-based addiction treatment (OBAT) clinics. We sought to understand the unique facilitators of and barriers to the integration of contraceptive services within the OBAT model with a goal to support the design and implementation of a program tailored to meet the reproductive health needs of patients with substance use disorder.

METHODS

After obtaining institutional review board approval, we conducted qualitative semistructured interviews with OBAT clinicians (registered nurses, advanced practice registered nurses, and physicians) at a tertiary-care safety-net hospital. Interview transcripts were analyzed using deductive codes utilizing key components of the Promoting Action on Research Implementation in Health Services and Ottawa Decision Support Frameworks.

RESULTS

We analyzed 20 interviews. Our data noted 3 major themes: (1) evidence to support integration of family planning and OBAT, (2) inherent strengths and facilitative factors of the OBAT model, and (3) barriers and challenges of the OBAT model influencing successful integration. Strengths included the destigmatizing and trust-building OBAT approach to care, common use of patient-centered counseling, and providers' nuanced understanding of substance use disorder-specific impacts on reproductive health. Barriers included time constraints, balancing urgent patient recovery needs, the desire for additional contraception provision training, and concern for potential contraceptive coercion.

CONCLUSIONS

Office-based addiction treatment clinics have inherent strengths that may make it a beneficial location for integrated family planning services. Future research should elicit patient perspectives to ensure the implementation of a family planning program in OBAT that supports patients' reproductive goals while avoiding stigma or reproductive coercion.

Enabling primary healthcare service development with patient participation: a qualitative study of the internal facilitator role in Norway

AIM

To explore how primary healthcare professionals (HCPs) tasked with facilitating primary healthcare service development with patient participation perceived their role.

INTRODUCTION

Patient participation in health service development is a recognized means of ensuring that health services fit the public's needs. However, HCPs are often uncertain about how to involve patient representatives (PRs), and patient participation is poorly implemented. Inspired by the Promoting Action on Research Implementation in Health Services framework, we address the innovation (patient participation), its recipients (PRs, HCPs, supervisors, and senior managers), and its context (primary healthcare at a local and organizational level).

METHODS

We conducted semi-structured individual interviews with six HCPs working as internal facilitators in primary healthcare in four Norwegian municipalities. The data were analyzed by applying Braun and Clarke's reflexive thematic analysis.

FINDINGS

The themes show that to develop primary healthcare services with patient participation, facilitators must establish a network of PRs with relevant skills, promote involvement within their organization, engage HCPs favorable toward patient participation, and demonstrate to supervisors and senior managers its usefulness to win their support. Implementing patient participation must be a shared, collective responsibility of facilitators, supervisors, and senior management. However, supervisors and senior management appear not to fully understand the potential of involvement or how to support the facilitators. The facilitator role requires continuous and systematic work on multiple organizational levels to enable the development of health services with patient participation. It entails maintaining a network of persons with experiential knowledge, engaging HCPs, and having senior management's understanding and support.

The use of GRADE-CERQual in qualitative evidence synthesis: an evaluation of fidelity and reporting

BACKGROUND

GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative Research) is a methodological approach to systematically and transparently assess how much confidence decision makers can place in individual review findings from qualitative evidence syntheses. The number of reviews applying GRADE-CERQual is rapidly expanding in guideline and other decision-making contexts. The objectives of this evaluation were, firstly, to describe the uptake of GRADE-CERQual in qualitative evidence synthesis by review authors and, secondly, to assess both reporting of and fidelity to the approach.

METHODS

The evaluation had two parts. Part 1 was a citation analysis and descriptive overview of the literature citing GRADE-CERQual. Authors worked together to code and chart the citations, first by title and abstract and second by full text. Part 2 was an assessment and analysis of fidelity to, and reporting of, the GRADE-CERQual approach in included reviews. We developed fidelity and reporting questions and answers based on the most recent guidance for GRADE-CERQual and then used NVivo12 to document assessments in a spreadsheet and code full-text PDF articles for any concerns that had been identified. Our assessments were exported to Excel and we applied count formulae to explore patterns in the data. We employed a qualitative content analysis approach in NVivo12 to sub-coding all the data illustrating concerns for each reporting and fidelity criteria.

RESULTS

233 studies have applied the GRADE-CERQual approach, with most (n = 225, 96.5%) in the field of health research. Many studies (n = 97/233, 41.6%) were excluded from full fidelity and reporting assessment because they demonstrated a serious misapplication of GRADE-CERQual, for example interpreting it as a quality appraisal tool for primary studies or reviews. For the remaining studies that applied GRADE-CERQual to assess confidence in review findings, the main areas of reporting concern involved terminology, labelling and completeness. Fidelity concerns were identified in more than half of all studies assessed.

CONCLUSIONS

GRADE-CERQual is being used widely within qualitative evidence syntheses and there are common reporting and fidelity issues. Most of these are avoidable and we highlight these as gaps in knowledge and guidance for applying the GRADE-CERQual approach.

Vaccine hesitancy among health-care professionals in the era of COVID-19

Health-care professionals (HCPs) are key trusted figures in addressing coronavirus disease 2019 (COVID-19) challenges. They are thought to influence others' health decisions by personal example. However, during the COVID-19 crisis, some HCPs hesitated to be vaccinated. We examined factors contributing to that decision. We performed 12 semi-structured interviews, between February and May 2021, with Israeli HCPs who had declined or delayed COVID-19 vaccination. Three coders conducted a combined top-down and bottom-up analysis. We identified four main themes shaping vaccine decision-making: (i) sources of information, (ii) perceptions of necessity and risks of the vaccine, (iii) individual versus collective responsibility and (iv) political climate and media influence. Participants were worried about long-term effectiveness and safety, and while many agreed that high-risk populations should be vaccinated, all considered themselves to be at low risk for serious disease. Some felt they should avoid taking a perceived risk (accepting a new vaccine) to protect society, although they felt pressured to do so. Vaccination campaign politization and the way the media approached the subject also contributed to mistrust and hesitancy to be vaccinated. These findings help us understand HCP beliefs and uncertainties about COVID-19 vaccinations. This study can help inform future campaigns targeted at HCPs to promote the acceptance of vaccines.

A Citation Review of 83 Dissemination and Implementation Theories, Models, or Frameworks Utilized in U.S.-Based Aging Research

BACKGROUND AND OBJECTIVES

Dissemination-implementation.org outlines 110 theories, models, and frameworks (TMFs): we conducted a citation analysis on 83 TMFs, searching Web of Science and PubMed databases.

RESEARCH DESIGN AND METHODS

Search terms were broad and included "aging," "older," "elderly," and "geriatric." We extracted each TMF in identified articles from inception through January 28, 2022. Included articles must have used a TMF in research or quality improvement work directly linked to older adults within the United States.

RESULTS

We reviewed 2,681 articles of which 295 articles cited at least one of 56 TMFs. Five TMFs represented 50% of the citations: Reach, Effectiveness, Adoption, Implementation, and Maintenance 1.0, Consolidated Framework for Implementation Research, Greenhalgh Diffusion of Innovation in Service Organizations, Quality Enhancement Research Initiative, Community-Based Participatory Research, and Promoting Action on Research Implementation in Health Services. TMF application varied and there was a steady increase in TMF citations over time, with a 2- to 3-fold increase in citations in 2020-2021. We identified that only 41% of TMF use was meaningful.

DISCUSSION AND IMPLICATIONS

Our results suggest TMF utilization is increasing in aging research, but there is a need to more meaningful utilize TMFs. As the population of older adults continues to grow, there will be increasing demand for effective evidence-based practices and models of care to be quickly and effectively translated into routine care. Use of TMFs is critical to building such evidence and to identifying and evaluating methods to support this translation.

Clinical research coordinators' role in knowledge translation activities in rehabilitation: a mixed methods study

BACKGROUND

Clinical research coordinators (CRCs) facilitate the interaction between researchers and knowledge users in rehabilitation centres to promote and sustain evidence-informed practices. Despite their presence in rehabilitation settings in Quebec for over 20 years, little is known about their profiles and knowledge translation (KT) activities nor how they can best enact their role. This study explored CRCs' roles and perspectives on the barriers, enablers, and strategies for improving KT activities in rehabilitation settings.

METHODS

We conducted a multi-centre, participatory sequential mixed methods study. In the descriptive quantitative phase, we collected data via an online survey to determine CRCs' role in research and KT. In the subsequent qualitative phase, we conducted an in-person focus group to elicit CRCs' perspectives regarding factors influencing their work in KT, and potential solutions for overcoming these challenges. We used a descriptive and an inductive content analysis approach for the data analysis. The data synthesis was inspired by the Promoting Action on Research Implementation in Health Services framework.

RESULTS

All nine CRCs from five partner health regions of a large rehabilitation research centre agreed to participate in the study. The data suggest that CRCs are like knowledge brokers and boundary spanners. As information managers, linkage agents and facilitators, CRCs play a pivot role in diffusion, dissemination, synthesis and tailoring of knowledge to improve evidence informed practices and quality of care in rehabilitation. The factors influencing CRCs' KT activities are mostly linked to the context such as the receptivity of the organization as well as the lack of time and resources, and limited understanding of their roles by stakeholders. Two main suggestions made to enhance CRCs' contribution to KT activities include the harmonisation of expectations between the large research centre and their partner health regions, and better promotion of their role to clinical and research teams.

CONCLUSIONS

This study provides valuable insights into the scope of CRCs' role. The results shed light on the challenges that they face and potential solutions to overcome them. The knowledge generated in this study can be used to implement this role with similar duties in rehabilitation settings or other health care domains.

A pragmatic context assessment tool (pCAT): using a Think Aloud method to develop an assessment of contextual barriers to change

BACKGROUND

The Consolidated Framework for Implementation Research (CFIR) is a determinant framework that can be used to guide context assessment prior to implementing change. Though a few quantitative measurement instruments have been developed based on the CFIR, most assessments using the CFIR have relied on qualitative methods. One challenge to measurement is to translate conceptual constructs which are often described using highly abstract, technical language into lay language that is clear, concise, and meaningful. The purpose of this paper is to document methods to develop a freely available pragmatic context assessment tool (pCAT). The pCAT is based on the CFIR and designed for frontline quality improvement teams as an abbreviated assessment of local facilitators and barriers in a clinical setting.

METHODS

Twenty-seven interviews using the Think Aloud method (asking participants to verbalize thoughts as they respond to assessment questions) were conducted with frontline employees to improve a pilot version of the pCAT. Interviews were recorded and transcribed verbatim; the CFIR guided coding and analyses.

RESULTS

Participants identified several areas where language in the pCAT needed to be modified, clarified, or allow more nuance to increase usefulness for frontline employees. Participants found it easier to respond to questions when they had a recent, specific project in mind. Potential barriers and facilitators tend to be unique to each specific improvement. Participants also identified missing concepts or that were conflated, leading to refinements that made the pCAT more understandable, accurate, and useful.

CONCLUSIONS

The pCAT is designed to be practical, using everyday language familiar to frontline employees. The pCAT is short (14 items), freely available, does not require research expertise or experience. It is designed to draw on the knowledge of individuals most familiar with their own clinical context. The pCAT has been available online for approximately two years and has generated a relatively high level of interest indicating potential usefulness of the tool.

Mobilising Implementation of i-PARIHS (Mi-PARIHS): development of a facilitation planning tool to accompany the Integrated Promoting Action on Research Implementation in Health Services framework

BACKGROUND

Facilitation makes the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework a popular framework in the field of implementation science. Facilitation allows for flexible application of the i-PARIHS framework by encouraging the iterative tailoring of implementation strategies to a dynamic context. However, successfully harnessing this flexibility can be challenging to navigate, particularly for novice facilitators. Therefore, to support and promote more widespread use of the i-PARIHS framework, and to make it easier for people who are already using i-PARIHS, we have undertaken the Mi-PARIHS Project-Mobilising Implementation of i-PARIHS, focused on developing a suite of practical and pragmatic i-PARIHS resources.

METHODS

Through a co-design approach drawing on end-users' experiences, we developed the Mi-PARIHS Facilitation Planning Tool, and this article reports on the final end-user feedback via an online survey.

RESULTS

A total of 58 participants completed the online survey. The survey focused on participants' previous experiences with i-PARIHS, their feedback on the background information provided with the Mi-PARIHS Tool, and their feedback on the tool itself (e.g. clarity, use, satisfaction, improvements). This feedback resulted in the development of a comprehensive 34-item Mi-PARIHS Facilitation Planning Tool that supports i-PARIHS users in their (1) assessment of the i-PARIHS framework's innovation, context, and recipient constructs; (2) development of a tailored facilitation plan; and (3) repeated use over time to evaluate the effectiveness of facilitation strategies.

CONCLUSIONS

The Mi-PARIHS Facilitation Planning Tool makes framework-guided implementation more accessible and reliable to a wider range of systems and stakeholders, thereby contributing to more consistent implementation of evidence-based practices and other innovations. It addresses the challenge of systematically assessing core constructs of the i-PARIHS framework to develop tailored facilitation strategies. The Mi-PARIHS Facilitation Planning Tool is freely available for use at the website https://www.flinders.edu.au/caring-futures-institute/Mi-PARIHS-tool .

Implementing a Care Pathway for small and nutritionally at-risk infants under six months of age: A multi-country stakeholder consultation

Nutritional vulnerability under the age of 6 months is prevalent in low- and middle-income countries with 20.1% infants underweight, 21.3% wasted and 17.6% stunted in a recent review. A novel Care Pathway for improved management of small and nutritionally at-risk infants under 6 months and their mothers (MAMI) has recently been developed to provide outpatient care at large coverage. We aimed to investigate stakeholders' views on the feasibility of its implementation and to identify barriers and enablers. This was an early stage formative mixed-methods study: an online survey plus in-depth interviews with country-level stakeholders in nutrition and child health from different geographical regions and stakeholder groups. 189 stakeholders from 42 countries responded to the online survey and 14 remote interviews were conducted. Participants expressed an urgent need for improved detection and care for small and nutritionally at-risk infants under 6 months. Whilst they considered the MAMI Care Pathway feasible and relevant, they noted it was largely unknown in their country. The most mentioned implementation barriers were: community-specific needs and health care seeking barriers, health workers' lack of competence in breastfeeding counselling and the absence of a validated anthropometric screening method. Possible enablers for its implementation were: patients' preference for outpatient care, integrating the MAMI care pathway into existing maternal and child health programmes and the possibility of a local pilot project. Adaptation to the local context was considered crucial in further scale-up.

Facilitating facilitators to facilitate-Some general comments on a strategy for knowledge implementation in health services

Numerous endeavours to ensure that day-to-day healthcare is both evidence-based and person-centred have generated extensive, although partial, comprehension of what guarantees quality improvement. To address quality issues, researchers and clinicians have developed several strategies as well as implementation theories, models, and frameworks. However, more progress is needed regarding how to facilitate guideline and policy implementation that guarantees effective changes take place in a timely and safe manner. This paper considers experiences of engaging and supporting local facilitators in knowledge implementation. Drawing on several interventions, considering both training and support, this general commentary discusses whom to engage and the length, content, quantity, and type of support along with expected outcomes of facilitators' activities. In addition, this paper suggests that patient facilitators could help produce evidence-based and person-centred care. We conclude that research about the roles and functions of facilitators needs to include more structured follow-ups and also improvement projects. This can increase the speed of learning with respect to what works, for whom, in what context, why (or why not), and with what outcomes when it comes to facilitator support and tasks.

Understanding context in the implementation of emergency obstetric and neonatal care in health facilities in Osun State, Nigeria- a mixed-methods study

BACKGROUND

Successful implementation of Emergency Obstetric and Neonatal Care (EmONC) is likely to improve pregnancy outcomes and is essential for quality maternity care. Context in implementation is described as factors that enabled or disabled implementation of interventions. While the context of implementation is important for the effectiveness of evidence-based interventions, the context of EmONC implementation has not been widely studied in Nigeria.

METHODS

The research design was cross-sectional descriptive. A mixed-methods approach was used to assess and explore the context of implementing EmONC in referral centres in Osun state. A purposive sampling technique was used to select the three tertiary health facilities in Osun State and six secondary health facilities from the six administrative zones in the State. A total of 186 healthcare providers in these referral centres participated in the quantitative part of the study, and eighteen in-depth interviews were conducted for its qualitative aspect. An adapted questionnaire from Context Assessment Index and an interview guide were used to collect data. Quantitative data were analysed using descriptive and inferential statistics at 0.05 significance level, while qualitative data were analysed using the thematic approach.

RESULTS

The percentage mean score of context strength in EmONC implementation was 63% ± 10.46 in secondary and 68% ± 10.47 in tertiary health facilities. There was a significant difference in the leadership (F (1, 184) = 8.35, p < 0.01), evaluation (F (1, 184) = 5.35, p = 0.02) and overall context (F (1, 184) = 6.46, p = 0.01) of EmONC implementation in secondary and tertiary health facilities. Emerging themes in EmONC context were: Resources for EmONC implementation; Demand for EmONC; Efficiency of funding; Institutional leadership; and Performance evaluation.

CONCLUSIONS

The context of EmONC implementation in the referral health facilities was generally weak. The secondary health facilities' weaknesses were worse compared to the tertiary health facilities. The five key contextual factors could inform strategies for improving EmONC implementation in health facilities to ensure improved access to care that will reduce deaths from obstetric complications in Nigeria.

Conceptual and relational advances of the PARIHS and i-PARIHS frameworks over the last decade: a critical interpretive synthesis

BACKGROUND

The number of research publications reporting the use of the Promoting Action on Research Implementation in Health Services (PARIHS) framework and the integrated PARIHS (i-PARIHS) framework has grown steadily. We asked how the last decade of implementation research, predicated on the (i-)PARIHS framework (referring to the PARIHS or i-PARIHS framework), has contributed to our understanding of the conceptualizations of, relationships between, and dynamics among the core framework elements/sub-elements. Building on the Helfrich et al. (2010) review of research on the PARIHS framework, we undertook a critical interpretive synthesis to: (1) identify conceptual and relational advances in the (i-)PARIHS framework and (2) identify conceptual and relational aspects of the (i-)PARIHS framework that warrant further work.

METHODS

We performed a systematic search in PubMed/PubMed Central, Ovid MEDLINE, CINAHL, JSTOR, SCOPUS, Web of Science, and PsycInfo. Articles were eligible for synthesis if they (a) were peer-reviewed articles, written in English, and published between January 2009 and December 2021, (b) applied the (i-)PARIHS framework explicitly to guide implementation research, and (c) made conceptual (expanding the conceptualization of core elements) and/or relational contributions (elaborating relationships among elements/sub-elements, or theorizing the relationships using empirical data). We used a critical interpretive synthesis approach to synthesize conceptual-relational advances of the (i-)PARIHS framework.

RESULTS

Thirty-seven articles were eligible for synthesis. Twenty-four offered conceptual contributions, and 18 offered relational contributions (5 articles contributed in both ways). We found conceptual expansion of all core (i-)PARIHS elements, with most emphasis on context (particularly outer context and leadership), facilitation, and implementation success. Articles also gave insights into the complex relationships and relational dynamism among these elements, characterized as contingent, interactive, multilevel, and temporal effects.

CONCLUSIONS

We observed developmental advances of the (i-)PARIHS framework and proposed several directions to further advance the framework. Conceptualization of (i-)PARIHS elements (particularly evidence/innovation and recipients) need to be further developed by specifying conceptual and operational definitions of underlying sub-elements. Relationships among (i-)PARIHS elements/sub-elements need to be further elaborated through empirical studies that consider situational contingencies and causal complexities. This will require examining necessity and sufficiency of (i-)PARIHS elements/sub-elements in relation to implementation outcomes, interactions among elements, and mechanism-based explanations.

Barriers and enablers to implementation of the therapeutic engagement questionnaire in acute mental health inpatient wards in England: A qualitative study

A strong association exists between the quality of nurse-service user therapeutic relationship and care outcomes on acute mental health inpatient wards. Despite evidence that service users desire improved therapeutic engagement, and registered mental health nurses recognize the benefits of therapeutic relationships, such interactions remain sub-optimal. There is a dearth of evidence on factors influencing implementation of interventions to support and encourage therapeutic engagement. This study aimed to understand the barriers and enablers to implementation of the Therapeutic Engagement Questionnaire (TEQ), across fifteen acute inpatient wards in seven English mental health organizations. Qualitative methods were used in which data were collected from ethnographic field notes and documentary review, coded, and analysed using thematic analysis. Theoretical framing supported data analysis and interpretation. Reporting adheres to the Standards for Reporting Qualitative Research. The TEQ as an evidence-based intervention co-produced with service users and nurses was valued and welcomed by many nurse directors, senior clinicians, and ward managers. However, a range of practical and perceptual factors impeded implementation. Furthermore, many existing contextual challenges for intervention implementation in acute inpatient wards were magnified by the COVID-19 pandemic. Suitable facilitation to address these barriers can help support implementation of the TEQ, with some transferability to implementation of other interventions in these settings. Our study suggests several facilitation methods, brought together in a conceptual model, including encouragement of reflective, facilitative discussion meetings among stakeholders and researchers, effort put into winning nurse 'buy-in' and identifying and supporting ward-level agents of change.

Embedding research (ER) led by nurses, midwives and allied health professionals (NMAHPs): the NMAHP-ER model

BACKGROUND

Previous embedded researcher models have focused predominantly on an individual being a temporary team member and embedded for a project-limited short-term placement.

AIM

To develop an innovative research capacity building model to address the challenges of developing, embedding and sustaining, research led by Nurses, Midwives, and Allied Health Professionals (NMAHPs) in complex clinical environments. This healthcare and academic research partnership model offers an opportunity to support the 'how' of enabling NMAHP research capacity building from within the researchers' clinical area of expertise.

METHOD

Collaboration between three healthcare and academic organisations and the iterative process of cocreation, development and refinement took place over 6 months during 2021. The collaboration relied on virtual meetings, emails, telephone calls and document review.

RESULTS

A codesigned NMAHP embedded research (ER) model is ready for trialling with the individual being an existing clinician working collaboratively within the healthcare setting and with academia to develop the skills to become the ER.

CONCLUSION

This model supports NMAHP-led research activity in clinical organisations in a visible and manageable way. As a shared, long-term vision, the model will contribute to research capacity and capability of the wider healthcare workforce. It will lead, facilitate and support research in and across clinical organisations in collaboration with higher education institutions.

Using i-PARIHS to assess implementation of the Surgical Safety Checklist: an international qualitative study

Background

Strategies selected to implement the WHO’s Surgical Safety Checklist (SSC) are key factors in its ability to improve patient safety. Underutilization of implementation frameworks for informing implementation processes hinders our understanding of the checklists’ varying effectiveness in different contexts. This study explored the extent to which SSC implementation practices could be assessed through the i-PARIHS framework and examined how it could support development of targeted recommendations to improve SSC implementation in high-income settings.

Methods

This qualitative study utilized interviews with surgical team members and health administrators from five high-income countries to understand the key elements necessary for successful implementation of the SSC. Using thematic analysis, we identified within and across-case themes that were mapped to the i-PARIHS framework constructs. Gaps in current implementation strategies were identified, and the utility of i-PARIHS to guide future efforts was assessed.

Results

Fifty-one multi-disciplinary clinicians and health administrators completed interviews. We identified themes that impacted SSC implementation in each of the four i-PARIHS constructs and several that spanned multiple constructs. Within innovation, a disconnect between the clinical outcomes-focused evidence in the literature and interviewees’ patient-safety focus on observable results reduced the SSC’s perceived relevance. Within recipients, existing surgical team hierarchies impacted checklist engagement, but this could be addressed through a shared leadership model. Within context, organizational priorities resulting in time pressures on surgical teams were at odds with SSC patient safety goals and reduced fidelity. At a health system level, employing surgical team members through the state or health region resulted in significant challenges in enforcing checklist use in private vs public hospitals. Within its facilitation construct, i-PARIHS includes limited definitions of facilitation processes. We identified using multiple interdisciplinary champions; establishing checklist performance feedback mechanisms; and modifying checklist processes, such as implementing a full-team huddle, as facilitators of successful SSC implementation.

Conclusion

The i-PARIHS framework enabled a comprehensive assessment of current implementation strategies, identifying key gaps and allowed for recommending targeted improvements. i-PARIHS could serve as a guide for planning future SSC implementation efforts, however, further clarification of facilitation processes would improve the framework’s utility.

Trial registration

No health care intervention was performed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08680-1.

Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO): a pragmatic cluster randomised controlled trial evaluating the effectiveness of a facilitation intervention on recognition and response to clinical deterioration

BACKGROUND

Most hospitals use physiological signs to trigger an urgent clinical review. We investigated whether facilitation could improve nurses' vital sign measurement, interpretation, treatment and escalation of care for deteriorating patients.

METHODS

In a pragmatic cluster randomised controlled trial, we randomised 36 inpatient wards at four acute hospitals to receive standard clinical practice guideline (CPG) dissemination to ward staff (n=18) or facilitated implementation for 6 months following standard dissemination (n=18). Expert, hospital and ward facilitators tailored facilitation techniques to promote nurses' CPG adherence. Patient records were audited pre-intervention, 6 and 12 months post-intervention on randomly selected days. Escalation of care as per hospital policy was the primary outcome at 6 and 12 months after implementation. Patients, nurses and assessors were blinded to group assignment. Analysis was by intention-to-treat.

RESULTS

From 10 383 audits, improved escalation as per hospital policy was evident in the intervention group at 6 months (OR 1.47, 95% CI (1.06 to 2.04)) with a complete set of vital sign measurements sustained at 12 months (OR 1.22, 95% CI (1.02 to 1.47)). There were no significant differences in escalation of care as per hospital policy between study groups at 6 or 12 months post-intervention. After adjusting for patient and hospital characteristics, a significant change from T0 in mean length of stay between groups at 12 months favoured the intervention group (-2.18 days, 95% CI (-3.53 to -0.82)).

CONCLUSION

Multi-level facilitation significantly improved escalation as per hospital policy at 6 months in the intervention group that was not sustained at 12 months. The intervention group had increased vital sign measurement by nurses, as well as shorter lengths of stay for patients at 12 months. Further research is required to understand the dose of facilitation required to impact clinical practice behaviours and patient outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12616000544471p.

A citation analysis and scoping systematic review of the operationalization of the Practical, Robust Implementation and Sustainability Model (PRISM)

Background

The Practical, Robust Implementation and Sustainability Model (PRISM) was developed in 2008 as a contextually expanded version of the broadly used Reach, Adoption, Effectiveness, Implementation, and Maintenance (RE-AIM) framework. PRISM provides researchers a pragmatic and intuitive model to improve translation of research interventions into clinical and community practice. Since 2008, the use of PRISM increased across diverse topics, populations, and settings. This citation analysis and scoping systematic review aimed to assess the use of the PRISM framework and to make recommendations for future research.

Methods

A literature search was conducted using three databases (PubMed, Web of Science, Scopus) for the period of 2008 and September 2020. After exclusion, reverse citation searches and invitations to experts in the field were used to identify and obtain recommendations for additional articles not identified in the original search. Studies that integrated PRISM into their study design were selected for full abstraction. Unique research studies were abstracted for information on study characteristics (e.g., setting/population, design), PRISM contextual domains, and RE-AIM outcomes.

Results

A total of 180 articles were identified to include PRISM to some degree. Thirty-two articles representing 23 unique studies integrated PRISM within their study design. Study characteristics varied widely and included studies conducted in diverse contexts, but predominately in high-income countries and in clinical out-patient settings. With regards to use, 19 used PRISM for evaluation, 10 for planning/development, 10 for implementation, four for sustainment, and one for dissemination. There was substantial variation across studies in how and to what degree PRISM contextual domains and RE-AIM outcomes were operationalized and connected. Only two studies directly connected individual PRISM context domains with RE-AIM outcomes, and another four included RE-AIM outcomes without direct connection to PRISM domains.

Conclusions

This is the first systematic review of the use of PRISM in various contexts. While there were low levels of ‘integrated’ use of PRISM and few reports on linkage to RE-AIM outcomes, most studies included important context domains of implementation and sustainability infrastructure and external environment. Recommendations are provided for more consistent and comprehensive use of and reporting on PRISM to inform both research and practice on contextual factors in implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01234-3.

Improving the Physical Health of Psychiatric Hospital Residents: An Evaluation of an Obesity Education Program for Mental Health Professionals

Background: People living with mental health disorders are at increased risk for developing obesity due to poor diet, physical inactivity, and antipsychotic medications. In the United States, the obesity rate is 36% in the general population and more than 50% for people living with mental health disorders. Although mental health clinicians concentrate on managing psychiatric disorders, they seldom recognize the gradual increase in body mass index of their patients. The result is a disconnection between the clinical management of psychiatric disorders and the medical management of obesity. Purpose: This study assessed the effectiveness of an evidence-based education program for improving the obesity management practices of mental health clinicians caring for residents at a state psychiatric hospital. Methods: This was a quasi-experimental study design with a pretest and posttest evaluation. Convenience sampling was used to recruit mental health professionals, or clinicians, at a large psychiatric hospital in the Southern region of the United States. Data was collected with the Advising and Treating Overweight and Obese Patient questionnaire (17 items). Data analysis included descriptive and inferential statistics. The findings were reported in accordance with the TREND and GREET guidelines. Results: The education program was completed by 50 MHCs. The pretest indicated that 76% of MHCs were not involved in helping obese residents manage their weight, but the posttest indicated 90% were involved. There was a significant increase in MHC knowledge about obesity management and reported actions 90-days after the program. MHCs were unable to arrange follow-up visits for residents, a task not directly within their control. Conclusions: Mental health clinicians reported increased knowledge and improved clinical practice after an education program. Because the outcomes were reported at 90-days after the program, further research needs to evaluate the longitudinal impact of this type of program, where the reported behaviors are correlated to process and clinical outcome measures for obesity.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

International Registered Report Identifier (IRRID)

DERR1-10.2196/40611

Development of a qualitative data analysis codebook informed by the i-PARIHS framework

Background

The Integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and its predecessor, PARIHS, have been widely utilized in implementation studies. Although i-PARIHS developers have focused on creating tools to guide facilitators in its application in practice, tools are also needed for evaluation and research. Codebooks with clear and meaningful code labels and definitions are an important component of qualitative data analysis and have been developed for other widely used frameworks. There is no such codebook for i-PARIHS. Additionally, sub-constructs for the Innovation, Recipients, and Context constructs lack definitions, and there is no sub-classification of facilitation activities for the Facilitation construct. The lack of a standardized codebook hinders our ability to synthesize research findings across studies, explore and test the range of activities that are utilized in facilitation efforts, and potentially validate and further refine i-PARIHS. This paper describes a rigorous process of developing a detailed qualitative codebook informed by the i-PARIHS framework.

Methods

A workgroup of qualitative researchers conducted a rigorous four-phase process to develop a codebook informed by i-PARIHS. In phase 1, workgroup members reviewed and discussed literature, consulted an organizational scientist, and drafted and refined subcodes and definitions for i-PARIHS constructs. In phase 2, they obtained feedback from an expert panel and further refined subcodes and definitions. In phase 3, they obtained feedback from i-PARIHS developers/experts and incorporated it into the codebook. Finally, two studies piloted the application of the codebook which informed the final version.

Results

The resulting i-PARIHS-informed codebook includes definitions for the four main constructs of the framework: Innovation, Recipients, Context, and Facilitation; subcodes and definitions for characteristics of each of these constructs; and instructions for the suggested application of individual codes and use of the codebook generally.

Conclusions

The standardized codes and definitions in the codebook can facilitate data exploration, pattern identification, and insight development informed by the i-PARIHS framework. Qualitative analysts can also use them to explore interactions between i-PARIHS constructs, maximize the potential for comparing findings across studies, and support the refinement of the i-PARIHS framework using empirical findings from multiple studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00344-9.

The Key Driver Implementation Scale (KDIS) for practice facilitators: Psychometric testing in the “Southeastern collaboration to improve blood pressure control” trial

Background

Practice facilitators (PFs) provide tailored support to primary care practices to improve the quality of care delivery. Often used by PFs, the “Key Driver Implementation Scale” (KDIS) measures the degree to which a practice implements quality improvement activities from the Chronic Care Model, but the scale’s psychometric properties have not been investigated. We examined construct validity, reliability, floor and ceiling effects, and a longitudinal trend test of the KDIS items in the Southeastern Collaboration to Improve Blood Pressure Control trial.

Methods

The KDIS items assess a practice’s progress toward implementing: a clinical information system (using their own data to drive change); standardized care processes; optimized team care; patient self-management support; and leadership support. We assessed construct validity and estimated reliability with a multilevel confirmatory factor analysis (CFA). A trend test examined whether the KDIS items increased over time and estimated the expected number of months needed to move a practice to the highest response options.

Results

PFs completed monthly KDIS ratings over 12 months for 32 primary care practices, yielding a total of 384 observations. Data was fitted to a unidimensional CFA model; however, parameter fit was modest and could be improved. Reliability was 0.70. Practices started scoring at the highest levels beginning in month 5, indicating low variability. The KDIS items did show an upward trend over 12 months (all p < .001), indicating that practices were increasingly implementing key activities. The expected time to move a practice to the highest response category was 9.1 months for standardized care processes, 10.2 for clinical information system, 12.6 for self-management support, 13.1 for leadership, and 14.3 months for optimized team care.

Conclusions

The KDIS items showed acceptable reliability, but work is needed in larger sample sizes to determine if two or more groups of implementation activities are being measured rather than one.

Universal Mindfulness Training in Schools for Adolescents: a Scoping Review and Conceptual Model of Moderators, Mediators, and Implementation Factors

There is evidence that universal school-based mindfulness training (SBMT) can have positive effects for young people. However, it is unknown who benefits most from such training, how training exerts effects, and how implementation impacts effects. This study aimed to provide an overview of the evidence on the mediators, moderators, and implementation factors of SBMT, and propose a conceptual model that can be used both to summarize the evidence and provide a framework for future research. A scoping review was performed, and six databases and grey literature were searched. Inclusion and exclusion criteria were applied to select relevant material. Quantitative and qualitative information was extracted from eligible articles and reported in accordance with PRISMA-ScR guidelines. The search produced 5479 articles, of which 31 were eligible and included in the review. Eleven studies assessed moderators of SBMT on pupil outcomes, with mixed findings for all variables tested. Five studies examined the mediating effect of specific variables on pupil outcomes, with evidence that increases in mindfulness skills and decreases in cognitive reactivity and self-criticism post-intervention are related to better pupil outcomes at follow-up. Twenty-five studies assessed implementation factors. We discuss key methodological shortcomings of included studies and integrate our findings with existing implementation frameworks to propose a conceptual model. Widespread interest in universal SBMT has led to increased research over recent years, exploring who SBMT works for and how it might work, but the current evidence is limited. We make recommendations for future research and provide a conceptual model to guide theory-led developments.

Improving Mortality Through a Multihospital, Collaborative Quality Improvement Project

Improving hospital mortality is a key focus of quality and safety efforts at both the local and national level. Structured interventions can assist organizations in determining whether interventional efforts have led to sustained improvement. The PARiHS framework (Promoting Action on Research Implementation in Health Services) can assist organizations in implementing research into practice. This study investigates the use of the PARiHS framework in implementing a multihospital quality improvement project aimed at improving observed-to-expected mortality as measured by Vizient's Clinical Data Base (CDB). Structured interventions during the study period included mortality reviews, clinical documentation improvement opportunities, educational webinars, training and support in the use of CDB to explore ongoing opportunities for mortality improvement and quarterly reports to each participating hospital's leadership team on their performance. Data were gathered from an improvement collaborative in the Upper Midwest, which comprised 34 hospitals, of which 17 participated in the intervention. Measurement occurred from Quarter 4 2016 through Quarter 3 2020 and consisted of a preintervention, intervention, and postintervention period. Although both participating and nonparticipating hospitals achieved a significant reduction in their mortality observed-to-expected ratio from the preintervention period through the postintervention period, the participating hospitals achieved a greater reduction in their observed-to-expected mortality ratio ( P < 0.0004). In addition, the participating hospitals achieved a relative 21% improvement in the mortality domain rank of the Vizient Quality & Accountability Study.

A scoping review to identify and describe the characteristics of theories, models and frameworks of health research partnerships

Background

Engaging users of health research, namely knowledge users, as partners in the research process may to lead to evidence that is more relevant to the users. This may optimize the uptake of evidence in healthcare practice, resulting in improved health outcomes or more efficient healthcare systems. However, barriers to involving knowledge users in the research process exist. Theories, models and frameworks may help guide the process of involving knowledge users and address barriers to engaging with knowledge users in research; however, there is little evidence identifying or describing the theories, models and frameworks of health research partnerships.

Objectives

Identify and describe theories, models and frameworks of health research partnerships. Report on concepts of knowledge user engagement represented in identified theories, models and frameworks.

Methods

We conducted a scoping review. Database (MEDLINE, Embase, CINAHL, PCORI) and ancestry and snowball searches were utilized. Included articles were written in English, published between January 2005 and June 2021, specific to health, a research partnership, and referred to a theory, model or framework. No critical appraisal was conducted. We developed a coding framework to extract details related to the publication (e.g. country, year) and theory, model or framework (e.g. intended users, theoretical underpinning, methodology, methods of development, purpose, concepts of knowledge user engagement). One reviewer conducted data extraction. Descriptive statistics and narrative synthesis were utilized to report the results.

Results

We identified 21 874 articles in screening. Thirty-nine models or frameworks were included in data analysis, but no theory. Two models or frameworks (5%) were underpinned by theory. Literature review was the method (n = 11, 28%) most frequently used to develop a model or framework. Guiding or managing a partnership was the most frequently reported purpose of the model/framework (n = 14, 36%). The most represented concept of knowledge user engagement was principles/values (n = 36, 92%).

Conclusions

The models and frameworks identified could be utilized by researchers and knowledge users to inform aspects of a health research partnership, such as guidance or implementation of a partnership. Future research evaluating the quality and applicability of the models and frameworks is necessary to help partners decide which model or framework to implement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00877-4.

A knowledge implementation model in health system management based on the PARIHS model

BACKGROUND

The gap between knowledge and practice, along with postponing or not implementing research findings in practice and policy-making, is one of the reasons for low-quality services. Hence, this study aimed at presenting a model of knowledge implementation in health system management in Iran.

METHODS

The present two-phase study was first performed qualitatively using a directive content analysis approach based on the Promoting Action on Research Implementation in Health Services (PARIHS) model. The researchers extracted the barriers and facilitators by conducting semi-structured individual interviews. Then, in a three-stage Delphi study, 25 health experts determined the barrier removal strategies. Data were analysed using MAXQDA10 software.

RESULTS

 The content analysis of the interviews led to the emergence of 1212 codes under three categories of evidence, context and facilitation. The findings indicate that health managers make fewer decisions based on research findings. Instead, they make decisions regarding the experiences of service providers and organization data. In addition to the subcategories in the PARIHS model, the researchers extracted political, social and administrative factors under the context category. The relationships between the features of evidence, context, facilitation, barriers and strategies were presented in the final model.

CONCLUSION

 The presented model comprehensively emphasizes the evidence resources, context preparation, and facilitation of the knowledge implementation process.

Establishing the Geriatric Emergency Department Intervention in Queensland emergency departments: a qualitative implementation study using the i-PARIHS model

BACKGROUND

Frail older adults require specific, targeted care and expedited shared decision making in the emergency department (ED) to prevent poor outcomes and minimise time spent in this chaotic environment. The Geriatric Emergency Department Intervention (GEDI) model was developed to help limit these undesirable consequences. This qualitative study aimed to explore the ways in which two hospital implementation sites implemented the structures and processes of the GEDI model and to examine the ways in which the i-PARIHS (innovation-Promoting Action on Research Implementation in Health Services) framework influenced the implementation.

METHODS

Using the i-PARIHS approach to implementation, the GEDI model was disseminated into two hospitals using a detailed implementation toolkit, external and internal facilitators and a structured program of support. Following implementation, interviews were conducted with a range of staff involved in the implementation at both sites to explore the implementation process used. Transcribed interviews were analysed for themes and sub-themes.

RESULTS

There were 31 interviews with clinicians involved in the implementation, conducted across two hospitals, including interviews with the two external facilitators. Major themes identified included: (i) elements of the GEDI model adopted or (ii) adapted by implementation sites and (iii) factors that affected the implementation of the GEDI model. Both sites adopted the model of care and there was general support for the GEDI approach to the management of frail older people in the ED. Both sites adapted the structure of the GEDI team and the expertise of the team members to suit their needs and resources. Elements such as service focus, funding, staff development and service evaluation were initially adopted but adaptation occurred over time. Resourcing and cost shifting issues at the implementation sites and at the site providing the external facilitators negatively impacted the facilitation process.

CONCLUSIONS

The i-PARIHS framework provided a pragmatic approach to the implementation of the evidenced-based GEDI model. Passionate, driven clinicians ensured that successful implementation occurred despite unanticipated changes in context at both the implementation and host facilitator sites as well as the absence of sustained facilitation support.

Applying implementation science in mental health services: Technical assistance cases from the Mental Health Technology Transfer Center (MHTTC) network

OBJECTIVE

Critical gaps exist between implementation of effective interventions and the actual services delivered to people living with mental disorders. Many technical assistance (TA) efforts rely on one-time trainings of clinical staff and printed guidelines that alone are not effective in changing clinical practice. The Mental Health Technology Transfer Center (MHTTC) Network uses implementation science to accelerate the use of evidence-based practices (EBPs), improve performance, and bring about systems-level change.

METHOD

Four case examples illustrate how MHTTCs employ the Exploration-Preparation-Implementation-Sustainment (EPIS) implementation framework and intensive implementation strategies to educate clinicians, manage change, and improve processes. These examples include implementing motivational interviewing, cognitive-behavioral therapy for people with psychosis, strategies to decrease the no show rate for virtual appointments, and school mental health systems development.

RESULTS

From Preparation through Sustainment, MHTTCs successfully employed implementation strategies including learning communities, audit and feedback, and coaching to bring about change. Each project attended to inner and outer contexts to eliminate barriers. The examples also show the benefit of integrating process improvement alongside implementation.

CONCLUSIONS

The MHTTCs are a model for using implementation science to design technical assistance that leads to more successful practical execution of EBPs; thus reducing the gap between research and practice.

Finding the facts in an infodemic: framing effective COVID-19 messages to connect people to authoritative content

The public’s need for timely and trusted COVID-19 information remains high. Governments and global health agencies such as the WHO have sought to disseminate accurate and timely information to counteract misinformation and disinformation that has arisen as part of an ‘infodemic’—the overabundance of information on COVID-19—some accurate and some not. In early 2020, WHO began a collaboration with Google to run online public service announcements on COVID-19, in the form of search ads displayed above results of Google Search queries. Web-based text ads can drive online searchers of COVID-19 information to authoritative COVID-19 content but determining what message is most effective is a challenge. WHO wanted to understand which message framing, that is, the way in which ad information is worded for the public, leads searchers to click through to WHO content. WHO tested 71 text ads in English across four COVID-19 topics using a mix of message frames: descriptive, collective, gain, loss, appeals to values and emphasising reasons. Between 11 September 2020 and 23 November 2020, there were 13 million views of the experimental WHO text ads leading to 1.4 million click-throughs to the WHO website. Within the set of 71 ads, there was a large spread between the most effective and least effective messages; for messages on COVID-19, the best performing framings were more than twice as effective as the worst performing framings (18.7% vs 8.5% engagement rate). Health practitioners can apply the messaging tactics WHO found to be successful to rapidly optimise messages for their own public health campaigns and better reach the public with authoritative information. Similar collaboration between big technology companies and governments and global health agencies has the potential to advance public health.

The Rationale and Design of Behavioral Interventions for Management of Agitation in Dementia in a Multi-Site Clinical Trial

BACKGROUND

Agitation and aggression are common in patients with Alzheimer's disease and related dementias and pose a significant burden on patients, caregivers, and the healthcare systems. Guidelines recommend personalized behavioral interventions as the first-line treatment; however, these interventions are often underutilized. The Standardizing Care for Neuropsychiatric Symptoms and Quality of Life in Dementia (StaN) study (ClinicalTrials.gov Identifier # NCT0367220) is a multisite randomized controlled trial comparing an Integrated Care Pathway, that includes a sequential pharmacological algorithm and structured behavioral interventions, with treatment-as-usual to treat agitation in dementia in long-term care and inpatient settings.

OBJECTIVE

To describe the rationale and design of structured behavioral interventions in the StaN study.

METHODS

Structured behavioral interventions are designed and implemented based on the following considerations: 1) personalization, 2) evidence base, 3) dose and duration, 4) measurement-based care, and 5) environmental factors and feasibility.

RESULTS

The process to design behavioral interventions for each individual starts with a comprehensive assessment, followed by personalized, evidence-based interventions delivered in a standardized manner with ongoing monitoring of global clinical status. Measurement-based care is used to tailor the interventions and to integrate them with pharmacotherapy.

CONCLUSION

Individualized behavioral interventions in patients with dementia may be challenging to design and implement. Here we describe a process to design and implement individualized and structured behavioral interventions in the context of a multisite trial in long-term care and inpatient settings. This process can inform the design of behavioral interventions in future trials and in clinical settings for the treatment of agitation in dementia.

Evaluating factors that influenced the successful implementation of an evidence-based neonatal care intervention in Chinese hospitals using the PARIHS framework

Background

Evidence based interventions (EBIs) can improve patient care and outcomes. Understanding the process for successfully introducing and implementing EBIs can inform effective roll-out and scale up. The Promoting Action on Research Implementation in Health Services (PARIHS) framework can be used to evaluate and guide the introduction and implementation of EBIs. In this study, we used kangaroo mother care (KMC) as an example of an evidence-based neonatal intervention recently introduced in selected Chinese hospitals, to identify the factors that influenced its successful implementation. We also explored the utility of the PARIHS framework in China and investigated how important each of its constructs (evidence, context and facilitation) and sub-elements were perceived to be to successful implementation of EBIs in a Chinese setting.

Method

We conducted clinical observations and semi-structured interviews with 10 physicians and 18 nurses in five tertiary hospitals implementing KMC. Interview questions were organized around issues including knowledge and beliefs, resources, culture, implementation readiness and climate. We used directed content analysis to analyze the interview transcript, amending the PARIHS framework to incorporate emerging sub-themes. We also rated the constructs and sub-elements on a continuum from “low (weak)”, “moderate” or “high (strong)” highlighting the ones considered most influential for hospital level implementation by study participants.

Results

Using KMC as an example, our finding suggest that clinical experience, culture, leadership, evaluation, and facilitation are highly influential elements for EBI implementation in China. External evidence had a moderate impact, especially in the initial awareness raising stages of implementation and resources were also considered to be of moderate importance, although this may change as implementation progresses. Patient experience was not seen as a driver for implementation at hospital level.

Conclusion

Based on our findings examining KMC implementation as a case example, the PARIHS framework can be a useful tool for planning and evaluating EBI implementation in China. However, it’s sub-elements should be assessed and adapted to the implementation setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07493-6.

Process evaluations undertaken alongside randomised controlled trials in the hospital setting: A scoping review

Background

There is increasing recognition of the importance of undertaking process evaluations alongside implementation of health interventions by examining mechanisms of impact and contextual factors. However, a comprehensive synthesis of process evaluations undertaken alongside clinical trials in hospital settings is lacking. We undertook a scoping review to address this gap.

Methods

This review was guided by the methodological framework for scoping studies. Studies were identified using four databases; Ovid Medline, EBSCO CINAHL, EMBASE and Scopus. Two authors independently screened all titles and available abstracts, with a third author available to adjudicate. Studies were eligible for inclusion if they described a process evaluation undertaken alongside a randomised controlled trial in the hospital setting. Data were abstracted by one author and checked by two others and analysed both descriptively and using inductive content analysis.

Results

Data were extracted from 30 articles reporting on 15 trials, most of which were cluster randomised trials (c-RTs) (n = 12). The most common data collection methods used in process evaluations were interviews, questionnaires or surveys, and records or logs. Data analysis revealed three themes relative to how authors: use process data to interpret, understand and explain trial outcomes; evaluate responses to the intervention; and consider the implementation context.

Conclusions

Findings from this review demonstrate the complex nature of intervention implementation in the hospital setting. Overall, there is need for standardised reporting of process evaluations and more explicit descriptions of how authors use frameworks to guide their evaluation.

Assessing the impact of a mixed intervention model on the reduction of medication administration errors in an Australian hospital

BACKGROUND

Medication errors remain one of the most common types of incidents reported in Australian hospitals. Studies have reported that for every 10 medication administrations, a medication administration error is likely to occur and reach the patient, potentially contributing to a preventable patient harm.

OBJECTIVE

To assess the impact of a mixed intervention model on medication administration errors in an Australian hospital.

METHODS

Two types of intervention model (human and system orientated) were implemented through collaboration with key stakeholders (nurses, educators, and policy makers) to reduce medication administration errors across this 650-bed multisite Australian hospital from August 2018 to June 2019. To assess the impact of the mixed intervention model, the total number of reported medication errors and the number of medication administration errors were retrieved from the hospital electronic medication management system for 12 months before (from June 2017 to July 2018) and after (from July 2019 to June 2020) implementation of all interventions.

RESULTS

Implementation of a mixed intervention model through collaboration with stakeholders resulted in significant reduction in the number of medication administration errors, and those with harm (from 68 to 55%, P < 0.0001 and from 12 to 8%, P = 0.0001 respectively). Additionally, the severity of medication administration errors was also reduced (HR 0.562, 95% CI (0.298-1.062)) in the post-intervention phase.

CONCLUSION

Introducing a mixed intervention model reduces medication administration errors across health settings and has the potential to drive excellence in healthcare.

Using system thinking methodologies to address health care complexities and evidence implementation

BACKGROUND

Despite health care advances, artificial intelligence and government interventions aiming to improve the health and wellbeing of citizens, huge disparities and failures in care provision exist. This is demonstrated by the rising number of medical errors, increase in readmission rates and mortality rates, and the failure of many health systems to successfully cope with events, such as pandemics and natural disasters. This shortfall is in part because of the complexity of the health care system, the interconnectedness of various parts of service, funding models, the complexity of patients' conditions, patient and carer needs, and the clinical processes needed for patients via multiple providers.

OBJECTIVE

The objective of this paper is to describe the use of system thinking methodologies to address complex problems such as those in the public health and health services domains.

METHOD

A description of the system thinking methodology and its associated methods including causal loop diagrams, social network analysis and soft system methodology are described with examples in the health care setting.

RESULTS

There are various models of knowledge translation that have been employed including the Joanna Briggs Institute model of implementation of evidence into practice, the triple C, and the Promoting Action on Research Implementation in Health Services. However, many of these models are neither scalable nor sustainable, and are most effective for localized projects implemented by trained clinicians and champions in relevant settings.System thinking is essentially a modelling process, which aims to create opportunities for change via an appreciation of perspective, and recognition that complex problems are a result of interconnected factors. The article argues that systems thinking applications need to move beyond that of addressing complex health issues pertaining to a population, and rather consider complex problems surrounding the delivery of high-quality health care.

CONCLUSION

It is important that methods to implement systems thinking methodologies in health care settings are developed and tested.

Nurses and ward managers' perceptions of leadership in the evidence-based practice: A qualitative study

AIM

To describe nurses and ward managers' experiences with nursing leadership in the implementation of evidence-based practice.

BACKGROUND

The implementation of evidence-based practice requires to identify the most suitable styles of nursing leadership for the successful application.

DESIGN

A qualitative descriptive study.

METHODS

The study was carried out with 57 nurses (clinical nurses and ward managers) in eight focus groups from five public hospitals. Template analysis, using the Promoting Action on Research Implementation in Health Services framework, was used. The Consolidated Criteria for Reporting Qualitative Research guide was followed in planning and reporting this research.

RESULTS

Three types of nursing leadership were identified: traditional leadership, medium leadership and transformational leadership. Traditional leadership was the most frequent, with a predominance of bureaucratic tasks for ward managers, so implementation of evidence-based practice is difficult.

CONCLUSION

Nurses do not feel empowered and they perceive the changes as an imposition. In the absence of strong leadership for evidence-based practice, a natural leader emerges.

IMPLICATIONS FOR NURSING MANAGEMENT

Clinical nurses demand more empowerment for decision-making, and ward managers need clarity of roles. To create an environment favourable to evidence-based practice, it is necessary consider the role of the transformational leader.

Onset PrevenTIon of urinary retention in Orthopaedic Nursing and rehabilitation, OPTION-a study protocol for a randomised trial by a multi-professional facilitator team and their first-line managers' implementation strategy

BACKGROUND

The Onset PrevenTIon of urinary retention in Orthopaedic Nursing and rehabilitation, OPTION, project aims to progress knowledge translation vis-à-vis evidence-based bladder monitoring in orthopaedic care, to decrease the risk of urinary retention, and voiding complications. Urinary retention is common whilst in hospital for hip surgery. If not properly identified and managed, there is a high risk of complications, some lifelong and life threatening. Although evidence-based guidelines are available, the implementation is lagging.

METHODS

Twenty orthopaedic sites are cluster randomised into intervention and control sites, respectively. The intervention sites assemble local facilitator teams among nursing and rehabilitation staff, including first-line managers. The teams receive a 12-month support programme, including face-to-face events and on-demand components to map and bridge barriers to guideline implementation, addressing leadership behaviours and de-implementation of unproductive routines. All sites have access to the guidelines via a public healthcare resource, but the control sites have no implementation support. Baseline data collection includes structured assessments of urinary retention procedures via patient records, comprising incidence and severity of voiding issues and complications, plus interviews with managers and staff, and surveys to all hip surgery patients with interviews across all sites. Further assessments of context include the Alberta Context Tool used with staff, the 4Ps tool for preference-based patient participation used with patients, and data on economic aspects of urinary bladder care. During the implementation intervention, all events are recorded, and the facilitators keep diaries. Post intervention, the equivalent data collections will be repeated twice, and further data will include experiences of the intervention and guideline implementation. Data will be analysed with statistical analyses, including comparisons before and after, and between intervention and control sites. The qualitative data are subjected to content analysis, and mixed methods are applied to inform both clinical outcomes and the process evaluation, corresponding to a hybrid design addressing effectiveness, experiences, and outcomes.

DISCUSSION

The OPTION trial has a potential to account for barriers and enablers for guideline implementation in the orthopaedic context in general and hip surgery care in particular. Further, it may progress the understanding of implementation leadership by dyads of facilitators and first-line managers.

TRIAL REGISTRATION

The study was registered as NCT04700969 with the U.S. National Institutes of Health Clinical Trials Registry on 8 January 2021, that is, prior to the baseline data collection.

Action research improved general prerequisites for evidence-based practice

The present study was part of an action research project that was performed to implement a clinical pathway for patients on mechanical ventilation and simultaneously explore the implementation process in a Swedish intensive care unit. The aim of this questionnaire study was to evaluate whether an action research methodology could affect the general prerequisites for evidence-based practice (EBP). Informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework, the study included registered nurses, assistant nurses and anesthesiologists in the unit at start of the project (n = 50) and at follow-up (n = 44). Data was collected with the Evaluation Before Implementation Questionnaire and the Attitudes towards Guidelines Scale.

The results revealed that the general prerequisites for EBP in the setting improved. Compared to baseline measurements, the staff at follow-up conversed significantly more about the importance of the patients’ experiences, research utilization, context and facilitation, while changes with respect to clinical experiences were not significant. The attitudes towards guidelines were perceived as positive at baseline as well as at follow-up and did not significantly change.

Longer professional experience was associated with a slightly lower probability of perceiving that the importance of research utilization was discussed and reflected upon, while belonging to a profession with longer education was associated with a higher probability of this perception. Compared to registered nurses and assistant nurses, the anesthesiologists perceived, to a greater extent, that the importance of clinical experience was discussed and reflected upon in the setting, while there was no significant association with the length of professional experience and/or specific professions regarding the other components.

In conclusion, using action research to implement a clinical pathway methodology seems to set in motion various mechanisms that improve some but not all prerequisites that, according to the PARIHS framework, are advantageous for EBP.

Implementation Science: Application of Evidence-Based Practice Models to Improve Healthcare Quality

BACKGROUND

Translating research into practice is complex for clinicians, yet essential for high quality patient care. The field of implementation science evolved to address this gap by developing theoretical approaches to guide adoption and sustained implementation of practice changes. Clinicians commonly lack knowledge, time, and resources of how evidence-based practice (EBP) models can guide implementation, contributing to the knowledge-to-practice gap.

AIM

This paper aimed to equip clinicians and other healthcare professionals with implementation science knowledge, confidence, and models to facilitate EBP change in their local setting and ultimately improve healthcare quality, safety, and population health outcomes.

METHODS

The field of implementation science is introduced, followed by application of three select models. Models are applied to a clinical scenario to emphasize contextual factors, process, implementation strategies, and outcome evaluation. Key attributes, strengths, opportunities, and utilities of each model are presented, along with general resources for selecting and using published criteria to best fit clinical needs. Partnerships between implementation scientists and clinicians are highlighted to facilitate the uptake of evidence into practice.

LINKING EVIDENCE TO ACTION

Knowledge of implementation science can help clinicians adopt high-quality evidence into their practices. Application-oriented approaches can guide clinicians through the EBP processes. Clinicians can partner with researchers in advancing implementation science to continue to accelerate the adoption of evidence and reduce the knowledge-to-action gap.