1
|
McInnes E, Dale S, Bagot K, Coughlan K, Grimshaw J, Pfeilschifter W, Cadilhac DA, Fischer T, van der Merwe J, Middleton S. The Quality in Acute Stroke Care (QASC) global scale-up using a cascading facilitation framework: a qualitative process evaluation. BMC Health Serv Res 2024; 24:144. [PMID: 38287332 PMCID: PMC10823736 DOI: 10.1186/s12913-024-10617-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 01/18/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Variation in hospital stroke care is problematic. The Quality in Acute Stroke (QASC) Australia trial demonstrated reductions in death and disability through supported implementation of nurse-led, evidence-based protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS Protocols) following stroke. Subsequently, a pre-test/post-test study was conducted in acute stroke wards in 64 hospitals in 17 European countries to evaluate upscale of the FeSS Protocols. Implementation across countries was underpinned by a cascading facilitation framework of multi-stakeholder support involving academic partners and a not-for-profit health organisation, the Angels Initiative (the industry partner), that operates to promote evidence-based treatments in stroke centres. .We report here an a priori qualitative process evaluation undertaken to identify factors that influenced international implementation of the FeSS Protocols using a cascading facilitation framework. METHODS The sampling frame for interviews was: (1) Executives/Steering Committee members, consisting of academics, the Angels Initiative and senior project team, (2) Angel Team leaders (managers of Angel Consultants), (3) Angel Consultants (responsible for assisting facilitation of FeSS Protocols into multiple hospitals) and (4) Country Co-ordinators (senior stroke nurses with country and hospital-level responsibilities for facilitating the introduction of the FeSS Protocols). A semi-structured interview elicited participant views on the factorsthat influenced engagement of stakeholders with the project and preparation for and implementation of the FeSS Protocol upscale. Interviews were recorded, transcribed verbatim and analysed inductively within NVivo. RESULTS Individual (n = 13) and three group interviews (3 participants in each group) were undertaken. Three main themes with sub-themes were identified that represented key factors influencing upscale: (1) readiness for change (sub-themes: negotiating expectations; intervention feasible and acceptable; shared goal of evidence-based stroke management); (2) roles and relationships (sub-themes: defining and establishing roles; harnessing nurse champions) and (3) managing multiple changes (sub-themes: accommodating and responding to variation; more than clinical change; multi-layered communication framework). CONCLUSION A cascading facilitation model involving a partnership between evidence producers (academic partners), knowledge brokers (industry partner, Angels Initiative) and evidence adopters (stroke clinicians) overcame multiple challenges involved in international evidence translation. Capacity to manage, negotiate and adapt to multi-level changes and strategic engagement of different stakeholders supported adoption of nurse-initiated stroke protocols within Europe. This model has promise for other large-scale evidence translation programs.
Collapse
Affiliation(s)
- Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Simeon Dale
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia.
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia.
| | - Kathleen Bagot
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia
| | - Kelly Coughlan
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Jeremy Grimshaw
- Centre for Practice-Changing Research (CPCR), Ottawa Health Research Institute, Ottawa Hospital - General Campus; and University of Ottawa, Ottawa, ON, Canada
| | - Waltraud Pfeilschifter
- Department of Neurology and Clinical Neurophysiology, Städtisches Klinikum Lüneburg, Lüneburg, Germany
- Department of Neurology, Germany Centre of Neurology and Neurosurgery, Goethe University, Frankfurt am Main, University Hospital Frankfurt, Frankfurt, Germany
| | - Dominique A Cadilhac
- Translational Public Health Division, Stroke and Ageing Research, School of Clinical Sciences, Monash University, Melbourne, Australia
- Public Health, Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | | | | | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| |
Collapse
|
2
|
Fakha A, Leithaus M, de Boer B, van Achterberg T, Hamers JP, Verbeek H. Implementing Four Transitional Care Interventions for Older Adults: A Retrospective Collective Case Study. THE GERONTOLOGIST 2023; 63:451-466. [PMID: 36001088 PMCID: PMC10028228 DOI: 10.1093/geront/gnac128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Four interventions to improve care transitions between hospital and home or community settings for older adults were implemented in Leuven, Belgium over the past 4 years. These complex interventions consist of multiple components that challenge their implementation in practice. This study examines the influencing factors, strategies used to address challenges in implementing these interventions, and implementation outcomes from the perspectives of health care professionals involved. RESEARCH DESIGN AND METHODS This was a qualitative, collective case study that was part of the TRANS-SENIOR research network. Authors conducted semistructured interviews with health care professionals about their perceptions regarding the implementation. Thematic analysis was used, and the Consolidated Framework for Implementation Research guided the final data interpretation. RESULTS Thirteen participants were interviewed. Participants reported major implementation bottlenecks at the organizational level (resources, structure, and information continuity), while facilitators were at the individual level (personal attributes and champions). They identified engagement as the primary strategy used, and suggested other important strategies for the future sustainability of the interventions (building strategic partnerships and lobbying for policies to support transitional care). They perceived the overall implementation favorably, with high uptake as a key outcome. DISCUSSION AND IMPLICATIONS This study highlights the strong role of health care providers, being motivated and self-driven, to foster the implementation of interventions in transitional care in a bottom-up way. It is important to use implementation strategies targeting both the individual-level factors as well as the organizational barriers for transitional care interventions in the future.
Collapse
Affiliation(s)
- Amal Fakha
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
| | - Merel Leithaus
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Bram de Boer
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
| | - Theo van Achterberg
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Jan P Hamers
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
| | - Hilde Verbeek
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
| |
Collapse
|
3
|
Naar S, Fernandez MI, Todd L, Green SKS, Budhwani H, Carcone A, Coyle K, Aarons GA, MacDonell K, Harper GW. Understanding implementation completion of tailored motivational interviewing in multidisciplinary adolescent HIV clinics. IMPLEMENTATION RESEARCH AND PRACTICE 2023; 4:26334895231164585. [PMID: 37091536 PMCID: PMC10068499 DOI: 10.1177/26334895231164585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
Background Understanding the barriers and facilitators of implementation completion is critical to determining why some implementation efforts fail and some succeed. Such studies provide the foundation for developing further strategies to support implementation completion when scaling up evidence-based practices (EBPs) such as Motivational Interviewing. Method This mixed-methods study utilized the Exploration, Preparation, Implementation, and Sustainment framework in an iterative analytic design to compare adolescent HIV clinics that demonstrated either high or low implementation completion in the context of a hybrid Type III trial of tailored motivational interviewing. Ten clinics were assigned to one of three completion categories (high, medium, and low) based on percentage of staff who adhered to three components of implementation strategies. Comparative analysis of staff qualitative interviews compared and contrasted the three high-completion clinics with the three low-completion clinics. Results Results suggested several factors that distinguished high-completion clinics compared to low-completion clinics including optimism, problem-solving barriers, leadership, and staff stress and turnover. Conclusions Implementation strategies targeting these factors can be added to EBP implementation packages to improve implementation success. Plain Language Summary While studies have begun to address adherence to intervention techniques, this is one of the first studies to address organizational adherence to implementation strategies. Youth HIV providers from different disciplines completed interviews about critical factors in both the inner and outer context that can support or hinder an organization's adherence to implementation strategies. Compared to less adherent clinics, more adherent clinics reported more optimism, problem-solving, and leadership strengths and less staff stress and turnover. Implementation strategies addressing these factors could be added to implementation packages to improve implementation success.
Collapse
Affiliation(s)
- Sylvie Naar
- Center for Translational Behavioral Science, Florida State University, Tallahassee, FL, USA
| | - M. Isabel Fernandez
- Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern
University, Fort Lauderdale, FL, USA
| | - Lisa Todd
- Department of Family Medicine and Public Health Sciences, Wayne State University School of
Medicine, Detroit, MI, USA
| | - Sara K. Shaw Green
- Center for Translational Behavioral Science, Florida State University, Tallahassee, FL, USA
| | - Henna Budhwani
- Department of Health Care Organization and Policy, School of Public
Health, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - April Carcone
- Department of Family Medicine and Public Health Sciences, Wayne State University School of
Medicine, Detroit, MI, USA
| | | | - Gregory A. Aarons
- Department of Psychiatry, UC San Diego, La Jolla, CA, USA
- ACTRI Dissemination and Implementation Science Center, UC San Diego,
La Jolla, CA, USA
- Child and Adolescent Services Research
Center, San Diego, CA, USA
| | - Karen MacDonell
- Department of Family Medicine and Public Health Sciences, Wayne State University School of
Medicine, Detroit, MI, USA
| | - Gary W. Harper
- Department of Health Behavior and Health Education, School of Public
Health, University of Michigan School of Public
Health, Ann Arbor, MI, USA
| |
Collapse
|
4
|
Kwak L, Toropova A, Powell BJ, Lengnick-Hall R, Jensen I, Bergström G, Elinder LS, Stigmar K, Wåhlin C, Björklund C. A randomized controlled trial in schools aimed at exploring mechanisms of change of a multifaceted implementation strategy for promoting mental health at the workplace. Implement Sci 2022; 17:59. [PMID: 36050743 PMCID: PMC9438275 DOI: 10.1186/s13012-022-01230-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/02/2022] [Indexed: 11/29/2022] Open
Abstract
Background This study will explore implementation mechanisms through which a single implementation strategy and a multifaceted implementation strategy operate to affect the implementation outcome, which is fidelity to the Guideline For The Prevention of Mental Ill Health within schools. The guideline gives recommendations on how workplaces can prevent mental ill health among their personnel by managing social and organizational risks factors in the work environment. Schools are chosen as the setting for the study due to the high prevalence of mental ill health among teachers and other personnel working in schools. The study builds on our previous research, in which we compared the effectiveness of the two strategies on fidelity to the guideline. Small improvements in guideline adherence were observed for the majority of the indicators in the multifaceted strategy group. This study will focus on exploring the underlying mechanisms of change through which the implementation strategies may operate to affect the implementation outcome. Methods We will conduct a cluster-randomized-controlled trial among public schools (n=55 schools) in Sweden. Schools are randomized (1:1 ratio) to receive a multifaceted strategy (implementation teams, educational meeting, ongoing training, Plan-Do-Study-Act cycles) or a single strategy (implementation teams, educational meeting). The implementation outcome is fidelity to the guideline. Hypothesized mediators originate from the COM-B model. A mixed-method design will be employed, entailing a qualitative study of implementation process embedded within the cluster-randomized controlled trail examining implementation mechanisms. The methods will be used in a complementary manner to get a full understanding of the implementation mechanisms. Discussion This implementation study will provide valuable knowledge on how implementation strategies work (or fail) to affect implementation outcomes. The knowledge gained will aid the selection of effective implementation strategies that fit specific determinants, which is a priority for the field. Despite recent initiatives to advance the understanding of implementation mechanisms, studies testing these mechanisms are still uncommon. Trial registration ClinicalTrials.org dr.nr 2020-01214. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01230-7.
Collapse
Affiliation(s)
- Lydia Kwak
- Unit of Intervention and Implementation Research for Worker Health, Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Anna Toropova
- Unit of Intervention and Implementation Research for Worker Health, Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA.,Center for Dissemination & Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, USA.,Division of Infectious Diseases, John T. Milliken Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Rebecca Lengnick-Hall
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Irene Jensen
- Unit of Intervention and Implementation Research for Worker Health, Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Bergström
- Unit of Intervention and Implementation Research for Worker Health, Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Occupational and Public Health Sciences, Faculty of Health and Occupational Studies, Centre for Musculoskeletal Research, University of Gävle, Gävle, Sweden
| | - Liselotte Schäfer Elinder
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Centre for Epidemiology and Community Medicine, Stockholm, Stockholm Region, Sweden
| | | | - Charlotte Wåhlin
- Unit of Intervention and Implementation Research for Worker Health, Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Occupational and Environmental Medicine Center, Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine, Linköping University, Linköping, Sweden
| | - Christina Björklund
- Unit of Intervention and Implementation Research for Worker Health, Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
5
|
McGuier EA, Kolko DJ, Dubowitz H. Public policy and parent-child aggression: Considerations for reducing and preventing physical punishment and abuse. AGGRESSION AND VIOLENT BEHAVIOR 2022; 65:101635. [PMID: 36016766 PMCID: PMC9398194 DOI: 10.1016/j.avb.2021.101635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Parent-child physical aggression, including both physical punishment and abuse, remains a prevalent problem in the United States. In this paper, we briefly review the prevalence and harms of parent-child aggression and discuss changes in social norms and policies over the past several decades. Then, we discuss broad social policies influencing risk for parent-child physical aggression, policies relevant to reducing and preventing physical abuse, and policies relevant to reducing and preventing physical punishment. We close by considering future directions to strengthen research and evaluation and accelerate progress toward ending parent-child physical aggression.
Collapse
Affiliation(s)
| | - David J Kolko
- Department of Psychiatry, University of Pittsburgh School of Medicine
- Western Psychiatric Hospital, University of Pittsburgh Medical Center
| | - Howard Dubowitz
- Department of Pediatrics, University of Maryland School of Medicine
| |
Collapse
|
6
|
Hills HA, Lengnick-Hall R, Johnson KA, Vermeer W, Hendricks Brown C, McGovern M. Rapid adaptation during the COVID crisis: Challenges experienced in delivering service to those with opioid Use disorders. IMPLEMENTATION RESEARCH AND PRACTICE 2022; 3:26334895221096295. [PMID: 37091103 PMCID: PMC9924287 DOI: 10.1177/26334895221096295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Adaptation is an accepted part of implementing evidence-based practices. COVID-19 presented a unique opportunity to examine adaptation in evolving contexts. Delivering service to people with opioid use disorder during the pandemic required significant adaptation due to revised regulations and limited service access. This report evaluated changes to addiction medication services caused by the pandemic, challenges encountered in rapidly adapting service delivery, and initial impressions of which changes might be sustainable over time. Methods: Qualitatively-evaluated structured interviews (N = 20) were conducted in late 2020 with key informants in Pinellas County (FL) to assess the pandemic’s impact. Interviewees represented a cross-section of the professional groups including direct SUD/HIV service providers, and sheriff’s office, Department of Health, and regional clinical program administrative staff. The interview questions examined significant changes necessitated by the pandemic, challenges encountered in adapting to this evolving context, and considerations for sustained change. Results: The most significant changes to service delivery identified were rapid adaptation to a telehealth format, and modifying service consistent with SAMHSA guidance, to allow for ‘take-home’ doses of methadone. Limitations imposed by access to technology, and the retraining of staff and patients to give and receive service differently were the most common themes identified as challenging adaptation efforts. Respondents saw shifts towards telehealth as most likely to being sustained. Conclusions: COVID-19 provided an unprecedented opportunity to examine adaptation in a fast-paced, dynamic, and evolving context. Adaptations identified will only be sustained through multisystem collaboration and validation. Results suggest that additional components could be added to implementation frameworks to assess rapid adaptation during unplanned events, such as access to additional resources or local decision-making that impacts service delivery. Findings will also be integrated with quantitative data to help inform local policy decisions. Plain Language Summary: Adaptation is an accepted part of implementing evidencebased practices. COVID-19 presented a unique opportunity to examine rapid adaptation necessitated within evolving contexts. Delivering services to people with opioid use disorder required significant adaptation due to changing regulations and limited access to lifesaving services. This study examined changes in service delivery due to the pandemic, challenges encountered in rapid adaptation, and initial impressions of which changes might be sustainable over time. Qualitatively-evaluated structured interviews were conducted with a cross-section of professional groups (direct substance use disorder (SUD) and human immunodeficiency virus (HIV) service providers, and sheriff's office, Department of Health, and clinical program administrative staff) in Pinellas County (FL). The most significant changes to service delivery were rapid adaptation to a telehealth format and increased allowance for 'takehome' doses of methadone medication. Limitations imposed by access to technology, as well as the education of and staff and patients were the most common themes identified as challenges. Respondents saw shifts towards telehealth as most likely to be sustained. COVID-19 provided an unprecedented opportunity to examine adaptation in a fast-paced, dynamic, and evolving context. Adaptations will only be sustained through multisystem collaboration and validation. Findings suggest that additional components could be added to implementation frameworks to assess rapid adaptation during unplanned events, such as access to additional resources or local decision-making that impacts service delivery.
Collapse
Affiliation(s)
- Holly A. Hills
- Department of Mental Health Law and Policy (MHC 2636), College of
Behavioral and Community Sciences, University of South Florida, Tampa, FL
- Holly A. Hills, Department of Mental Health
Law and Policy (MHC 2636), College of Behavioral and Community Sciences,
University of South Florida, Tampa, FL, 33620.
| | | | - Kimberly A. Johnson
- Department of Mental Health Law and Policy (MHC 2636), College of
Behavioral and Community Sciences, University of South Florida, Tampa, FL
| | - Wouter Vermeer
- Department of Psychiatry and Behavioral Sciences, Feinberg School of
Medicine, Northwestern University, Chicago, IL, USA
| | - C. Hendricks Brown
- Department of Psychiatry and Behavioral Sciences, Feinberg School of
Medicine, Northwestern University, Chicago, IL, USA
| | - Mark McGovern
- Department of Psychiatry and Behavioral Sciences, Stanford University School of
Medicine, Palo Alto, CA, USA
- Division of Primary Care and Population Health, Department of
Medicine, Stanford University School of
Medicine, Palo Alto, CA, USA
| |
Collapse
|
7
|
Shattuck D, Richard BO, Jaramillo ET, Byrd E, Willging CE. Power and resistance in schools: Implementing institutional change to promote health equity for sexual and gender minority youth. FRONTIERS IN HEALTH SERVICES 2022; 2:920790. [PMID: 36873606 PMCID: PMC9979782 DOI: 10.3389/frhs.2022.920790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction Schools in the United States are hierarchical institutions that actively (re)produce the power relations of the wider social world, including those associated with heteronormativity. Structural stigma, informed by heteronormativity and perpetuated through schools, contributes to the production of academic and health disparities among youth who are lesbian, gay, bisexual, transgender, queer, or of other gender and sexual identities (LGBTQ+). We draw upon 5 years of qualitative data from a cluster randomized controlled trial conducted in New Mexico that used implementation science frameworks to promote the uptake and sustainment of evidence-informed practices (EIPs) to examine how power operates to hinder or promote the ability of school staff to change school environments, disrupt structural stigma, and increase safety and support for LGBTQ+ youth. Methods Data sources included annual individual and small group qualitative interviews with school professionals (e.g., administrators, school nurses, teachers, and other staff), several of whom took part in Implementation Resource Teams (IRTs) charged with applying the EIPs. Other data sources included bi-weekly periodic reflections with implementation coaches and technical assistance experts. Data were recorded, transcribed, and analyzed using deductive and inductive coding techniques. Results The IRTs experienced variable success in implementing EIPs. Their efforts were influenced by: (1) constraining school characteristics, including staff turnover and resource scarcity; (2) community-based opposition to change and concerns about community backlash; (3) the presence or absence of supportive school leadership; and (4) variations in school, district, and state policies affecting LGBTQ+ students and attitudes about their importance. Findings illustrate how diverse power structures operated in and across outer and inner contexts to bound, shift, amplify, and otherwise shape how new practices were received and implemented. Conclusion Findings indicate that the efforts of IRTs were often a form of resistant power that operated within and against school hierarchies to leverage epistemic, discursive, and material power toward implementation. To improve health equity, implementation scientists must attend to the multiple real and perceived power structures that shape implementation environments and influence organizational readiness and individual motivation. Implementers must also work to leverage resistant power to counter the institutional structures and social norms that perpetuate inequities, like heteronormativity and structural stigma.
Collapse
Affiliation(s)
| | | | | | - Evelyn Byrd
- Pacific Institute for Research and Evaluation
| | | |
Collapse
|
8
|
Kirk JW, Nilsen P, Andersen O, Stefánsdóttir NT, Grønfeldt B, Brødsgaard R, Pedersen BS, Bandholm T, Tjørnhøj-Thomsen T, Pedersen MM. Adaptations and modifications to a co-designed intervention and its clinical implementation: a qualitative study in Denmark. BMC Health Serv Res 2021; 21:1108. [PMID: 34656126 PMCID: PMC8520628 DOI: 10.1186/s12913-021-07142-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 10/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a long-standing debate in implementation research on whether adaptations to evidence-based interventions (EBIs) are desirable in health care. If an intervention is adapted and not delivered as conceived and planned, it is said to have low fidelity. The WALK-Cph project was developed based on the assumption that involving stakeholders in co-design processes would facilitate the fidelity of an intervention to increase the mobility of acutely admitted older medical patients and its implementation in two hospitals in Denmark. The purpose of this study is to describe and analyse adaptations and modifications that were made to the co-designed WALK-Cph intervention and its implementation. METHODS This study used a qualitative design. An ethnographic field study was performed using participant observations, workshops and semi-structured interviews. Data were analysed twice using the Framework Method. The first analysis was based on the frameworks from Stirman, Moore and Proctor. The second analysis, a retrospective modifications analysis, was based on the Adaptation-Impact Framework. RESULTS Many different types of adaptations and modifications were made to the WALK-Cph intervention and its implementation plan. Most of the modifications were made on the contents of the intervention. In total, 44 adaptations and modifications were made, of which 21 were planned (adaptations) and 23 were made haphazardly (modifications). Most of the content and context adaptations and modifications made on the intervention had a mixed result regarding enhanced fidelity. The retrospective modifications analysis showed that modifications were ongoing and both situationally and contextually shaped. CONCLUSIONS Although an extensive co-design process was carried out to facilitate the fidelity of the WALK-Cph intervention, this study showed that many adaptations and modifications were still made to both the intervention and its implementation plan. It could indicate that the co-design process had a small effect or that adaptations and modifications are ongoing and both situationally and contextually shaped, which challenge the assumption and the desire to be able to plan and control changes.
Collapse
Affiliation(s)
- Jeanette Wassar Kirk
- Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre, Kettegaard alle 30, 2650, Hvidovre, Danmark. .,Department of Public Health, Nursing, Aarhus University, Nordre Ringgade 1, 8000, Aarhus, Denmark.
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Linköping University, Sandbäcksgatan 7, 582 25, Linköping, Sweden
| | - Ove Andersen
- Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre, Kettegaard alle 30, 2650, Hvidovre, Danmark
| | - Nina Thórný Stefánsdóttir
- Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre, Kettegaard alle 30, 2650, Hvidovre, Danmark
| | - Birk Grønfeldt
- Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre, Kettegaard alle 30, 2650, Hvidovre, Danmark
| | - Rasmus Brødsgaard
- Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre, Kettegaard alle 30, 2650, Hvidovre, Danmark
| | - Britt Stævnsbo Pedersen
- Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre, Kettegaard alle 30, 2650, Hvidovre, Danmark.,Copenhagen Neuromuscular Center, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen Ø, Denmark
| | - Thomas Bandholm
- Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre, Kettegaard alle 30, 2650, Hvidovre, Danmark.,Department of Orthopedic Surgery, and Department of Physical and Occupational Therapy, Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Copenhagen University Hospital, Amager and Hvidovre, Kettegaards alle 30, 2650, Hvidovre, Denmark
| | - Tine Tjørnhøj-Thomsen
- Department of Health and Social Context, National Institute of Public Health, University of Southern Denmark, Studiestræde 6, 1455, Copenhagen K, Denmark
| | - Mette Merete Pedersen
- Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre, Kettegaard alle 30, 2650, Hvidovre, Danmark.,Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark
| |
Collapse
|