The impacts of implementing recovery innovations: a conceptual framework grounded in qualitative research

Background

Implementing mental health recovery into services is a policy priority in Canada and globally. To that end, a 5 year study was undertaken with seven organisations providing mental health and housing services to people living with a mental health challenge to implement guidelines for the transformation of services and systems towards a recovery-orientation. Multi-stakeholder implementation teams were established and a facilitated process guided teams to choosing and planning for the implementation of one recovery innovation. The recovery innovations chosen were hiring peer support workers, Wellness Recovery Action Planning (WRAP), a family support group, and staff recovery training.

Methods

This study reports on data collected at the post-implementation stage. 90 service users, service providers, family members, managers, other actors and knowledge users participated in 41 group, individual or dyad semi-structured interviews. The interview guides included open-ended questions eliciting participants’ impressions regarding the impact of implementing the innovation on service users, service providers and organisations. We applied a collaborative qualitative content analysis approach in NVivo12 to coding and interpreting the data generated from these questions.

Results

Eighteen impacts of implementing recovery innovations from the perspectives of diverse stakeholder groups were identified. Three impacts of working as an implementation team member and as part of a research project were also identified. Impacts were developed into a conceptual framework organised around four overall categories of impact: Ways of being, Ways of interacting, Ways of thinking, and Ways of operating and doing business.

Conclusions

The IMpacts of Recovery Innovations (IMRI) framework version 1 can assist researchers, evaluators and decision-makers identify, explore and understand impact in the context of recovery innovations. The framework helps fill a gap in conceptualising service and organisation-level impacts. Future research is needed to validate the framework and map it to existing methods for studying impact.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00559-2.

Translating mental health recovery guidelines into recovery-oriented innovations: A strategy combining implementation teams and a facilitated planning process

Recovery is the focus of mental health strategies internationally. However, little translation of recovery knowledge has occurred in mental health services. The purpose of this research is to bridge the gap between recovery guidelines and practice by developing a new implementation strategy involving the formation of implementation teams made up of different stakeholders (service users, service providers, managers, knowledge users) and facilitating a 12-meeting implementation planning process. Sevenmental health organizations across Canada successfully completed the process of translating the guidelines into a recovery-oriented innovation that was implemented. Fifty-five implementation team members were interviewed upon completion of the 12-meeting process. Findings indicate that implementation team members perceived the structured planning process as positive. Nevertheless, the language of implementation science remains difficult to understand for a non-academic audience. Key elements of the 12-meeting process included the value of consensus building among implementation team members and the subsequent shifting power relationships. While working with diverse stakeholders came with certain challenges, the process in itself was a form of system transformation. This type of engaged planning process was a significant departure from the more top-down approaches to organizational change that staff were used to.

Identifying and understanding the contextual factors that shaped mid-implementation outcomes during the COVID-19 pandemic in organizations implementing mental health recovery innovations into services

BACKGROUND

Seven housing and health services organizations were guided through a process of translating Chapter Six of the Canadian Guidelines for Recovery-Oriented Practice into a recovery-oriented innovation and plan for its implementation. At the time of the COVID-19 outbreak and lockdown measures, six of the seven organizations had begun implementing their chosen innovation (peer workers, wellness recovery action planning facilitator training, staff training and a family support group). This mid-implementation study used the Consolidated Framework for Implementation Research (CFIR) to identify contextual factors that influenced organizations to continue or postpone implementation of recovery-oriented innovations in the early months of the COVID-19 pandemic.

METHODS

Twenty-seven semi-structured 45-min interviews were conducted between May and June 2020 (21 implementation team members and six providers of the innovation (trainers, facilitators, peer workers). Interview guides and analysis were based on the CFIR. Content analysis combined deductive and inductive approaches. Summaries of coded data were given ratings based on strength and valence of the construct's impact on implementation. Ratings were visualized by mid-implementation outcome and recovery innovation to identify constructs which appear to distinguish between sites with a more or less favorable mid-implementation outcomes.

RESULTS

Four mid-implementation outcomes were observed at this snapshot in time (from most to least positive): continued implementation with adaptation (one site), postponement with adaptation and estimated relaunch date (four sites), indefinite postponement with no decision on relaunch date (one site), and no implementation of innovation yet (one site). Two constructs had either a negative influence (external policies and incentives-renamed COVID-19-related external policy for this study) or a positive influence (leadership engagement), regardless of implementation outcome. Four factors appeared to distinguish between more or less positive mid-implementation outcome: adaptability, implementation climate and relative priority, available resources, and formally appointed internal implementation leaders (renamed "engaging implementation teams during the COVID-19 pandemic" for this study).

CONCLUSIONS

The COVID-19 pandemic is an unprecedented outer setting factor. Studies that use the CFIR at the mid-implementation stage are rare, as are studies focusing on the outer setting. Through robust qualitative analysis, we identify the key factors that shaped the course of implementation of recovery innovations over this turbulent time.

The CFIR Card Game: a new approach for working with implementation teams to identify challenges and strategies

BACKGROUND

The Consolidated Framework for Implementation Research (CFIR) and the ERIC compilation of implementation strategies are key resources for identifying implementation barriers and strategies. However, their respective density and complexity make their application to implementation planning outside of academia challenging. We developed the CFIR Card Game as a way of working with multi-stakeholder implementation teams that were implementing mental health recovery into their services, to identify barriers and strategies to overcome them. The aim of this descriptive evaluation is to describe how the game was prepared, played, used and received by teams and researchers and their perception of the clarity of the CFIR constructs.

METHODS

We used the new CFIR-ERIC Matching Tool v.1 to design the game. We produced a deck of cards with each of the CFIR-ERIC Matching Tool barrier narratives representing all 39 CFIR constructs. Teams played the game at the pre-implementation stage at a time when they were actively engaged in a planning process for implementing their selected recovery-oriented innovation. The teams placed each card in either the YES or NO column of the board in response to whether they anticipated experiencing this barrier in their setting. Teams were also asked about the clarity of the barrier narratives and were provided with plain language versions if unclear. Researchers completed a reflection form following the game, and participants completed an open-added questionnaire that included questions specific to the CFIR Card Game. We applied a descriptive coding approach to analysis.

RESULTS

Four descriptive themes emerged from this analysis: (1) the CFIR Card Game as a useful and engaging process, (2) difficulties understanding CFIR construct barrier narratives, (3) strengths of the game's design and structure and room for improvement and (4) mediating factors: facilitator preparation and multi-stakeholder dynamics. Quantitative findings regarding the clarity of the barrier narratives were integrated with qualitative data under theme 2. Only seven of the 39 original barrier narratives were judged to be clear by all teams.

CONCLUSIONS

The CFIR Card Game can be used to enhance implementation planning. Plain language versions of CFIR construct barrier narratives are needed. Our plain language versions require further testing and refining.

High quality entanglement on a chip-based frequency comb

We report an efficient energy-time entangled photon-pair source based on four-wave mixing in a CMOS-compatible silicon photonics ring resonator. Thanks to suitable optimization, the source shows a large spectral brightness of 400 pairs of entangled photons /s/MHz for 500 μW pump power, compatible with standard telecom dense wavelength division multiplexers. We demonstrate high-purity energy-time entanglement, i.e., free of photonic noise, with near perfect raw visibilities (> 98%) between various channel pairs in the telecom C-band. Such a compact source stands as a path towards more complex quantum photonic circuits dedicated to quantum communication systems.

Recovery Communities of Practice: An Innovative Strategy for Mental Health System Transformation

This column describes the development of a "community of practice" (CoP) in Quebec, which was implemented in 2012 to promote recovery-oriented practices in mental health care. A group of diverse stakeholders work together to share and transfer knowledge; support diverse practices, strategies, and solutions; develop a culture of collaboration; mobilize opportunities for quality improvement; and influence decision-making bodies. Recent efforts have been successful: the provision of recovery-oriented services is the primary focus of the 2015-2020 Quebec Mental Health Action Plan.

Two-photon interference between disparate sources for quantum networking

Quantum networks involve entanglement sharing between multiple users. Ideally, any two users would be able to connect regardless of the type of photon source they employ, provided they fulfill the requirements for two-photon interference. From a theoretical perspective, photons coming from different origins can interfere with a perfect visibility, provided they are made indistinguishable in all degrees of freedom. Previous experimental demonstrations of such a scenario have been limited to photon wavelengths below 900 nm, unsuitable for long distance communication, and suffered from low interference visibility. We report two-photon interference using two disparate heralded single photon sources, which involve different nonlinear effects, operating in the telecom wavelength range. The measured visibility of the two-photon interference is 80 ± 4%, which paves the way to hybrid universal quantum networks.

A pilot prospective study of the vascular repair response following red cell transfusion in critically ill patients

BACKGROUND

Red blood cell transfusion has been associated with adverse outcomes including infection, delayed recovery and increased mortality in some patient populations. Circulating cells that yield endothelial-like vascular progenitor cell (VPC) clusters are correlated with vascular repair and recovery after ischaemic injury. The impact of red cell transfusion on VPC clusters and vascular repair remains uncertain.

STUDY DESIGN

We prospectively enrolled patients admitted to intensive care requiring red cell transfusion and subjects at low likelihood of requiring red cell transfusion. Levels of VPC clusters and plasma levels of angiogenic cytokines were compared. A total of 17 patients were recruited and had blood samples collected at time of enrolment and at 24-48 h, 48-72 h and 1 week following transfusion.

RESULTS

We could not discern differences in the number of VPC clusters between transfused patients (n = 6) and non-transfused subjects (n = 11) at baseline or throughout the study period. VPC cluster levels demonstrated wide variance and were highest at 24-h post-enrolment in the entire cohort. Furthermore, levels of all 16 cytokines analysed were not significantly different between transfused and non-transfused patients and we did not observe a correlation between cytokine concentrations and levels of circulating VPC-cluster forming cells in the overall study population.

CONCLUSIONS

Our data suggest that assessment of vascular repair responses after red blood cell transfusion in critically ill patients is challenging. Although our study did not allow us to discern an influence of red cell transfusion on VPC cluster levels or angiogenic cytokines, new methods evaluating vascular repair mechanisms may be required.

Inhibition of DNA polymerase-alpha by ara-CMP in the presence of a regulatory protein extracted from human promyelocytic leukemic cells (HL-60)

Cytotoxicity of arabinofuranosylcytosine (ara-C) has been related in vitro to the inhibition of the DNA polymerase activities by arabinosylcytosine triphosphate (ara-CTP) and the incorporation of ara-C into the DNA where, acting as a chain terminator, it slows the chain elongation. Induced in vitro cellular resistance to ara-C was shown to be secondary to altered deoxycytidine (dCyd) kinase activity, dCyd deaminase activity, or deoxynucleotides triphosphates (dNTP) pools. Recent studies reported no differences of ara-C metabolism in cells obtained from leukemic patients at diagnosis and at relapse after ara-C therapy, suggesting that unknown cellular biochemical determinants may be involved in acquisition of ara-C resistance. Using dialysed crude extracts of leukemic cells obtained from patients at diagnosis, we observed variable inhibition of their DNA polymerase activities by arabinosylcytosine monophosphate (ara-CMP) at 2 mmol/L (0% to 50% inhibition). In similar conditions, ara-CMP reduced the polymerase activities of human thymus extract by 35% and 55% in extract of HL-60 cells (cultured human promyelocytic cells). The ara-CMP factor responsible for inhibition of DNA polymerase activity was nondialysable, heat labile, proteinase K sensitive, and has an estimated molecular mass of 30 kilodalton by gel filtration. After partial purification, this protein had no DNA polymerase RNA polymerase activities. In presence of the regulator and ara-CMP at 2 mmol/L, we observed no inhibition of the HL-60 3'----5' and 5'----3' exonucleases activities, suggesting the regulator interaction being mainly with the DNA polymerases in presence of ara-CMP. The relevance of the presence or absence of this protein regarding the cell sensitivity to ara-C is under investigation.

The production and characterization of a monoclonal antibody specific for the 94,000 dalton enkephalin-degrading peptidase from rabbit kidney brush border

We have prepared a monoclonal antibody specific for a major 94,000 dalton protein from the brush border membrane of rabbit kidney cortex. The monoclonal antibody was used for the immunoaffinity purification of this protein after solubilization of brush border membranes with octylglucoside. The 94,000 dalton protein is a peptidase capable of cleaving the Gly3-Phe4 bond of methionine-enkephalin. Identification of this peptidase as a previously described 94,000 dalton enkephalinase of kidney cortex was confirmed by its sensitivity to EDTA and inhibitors such as thiorphan and phosphoramidon.

L'expression corporelle: Groupe thérapeutique

L'expression corporelle est un moyen d'évaluation et de traitement qui permet aux individus de manifester leur état intra-psychique sur le plan des besoins, des pulsions, des émotions, en prenant conscience de la capacité d'expression du corps sur un mode non-verbal et gestuel. L'évaluation et le traitement ont été étudiés en fonction des processus suivants: l'apprentissage, la prise de conscience et l'intériorisation du vécu. L'expression corporelle permet de prendre conscience de son corps, des gestes posés et de leur contenu affectif. Le fait de s'exprimer par gestes permet aux membres du groupe de communiquer sans artifice et d'établir un début de relation non-menaçante. Cette expérience est thérapeutique en autant qu'elle permette l'insight afin d'améliorer les échanges interpersonnels et ainsi favoriser une communication plus vraie, plus intense et plus enrichissante. L'expression corporelle permet et renforce des nouveaux modes de comportement que l'individu tentera de transposer dans sa vie.