Training registered nurses to conduct pre-implementation assessment to inform program scale-up: an example from the rural Transitions Nurse Program

Abstract Objectives Adapting evidence-based practices to local settings is critical for successful implementation and dissemination. A pre-implementation assessment evaluates local context to inform implementation, but there is little published guidance for clinician-implementers. The rural Transitions Nurse Program (TNP) is a care coordination intervention that facilitates care transitions for rural veterans. In year 1 of TNP, pre-implementation assessments were conducted by a centralized project team through multi-day visits at five sites nationwide. In year 2, we tested if local site TNP nurses could conduct pre-implementation assessments using evidence-based tools and coaching from the TNP team. This required developing a multicomponent pre-implementation strategy bundle to guide data collection and synthesis. We hypothesized that (1) nurses would find the pre-implementation assessment useful for tailoring TNP to local contexts and (2) nurses would identify similar barriers and facilitators to those identified at first year sites. Methods The bundle included guides for conducting key informant interviews, brainwriting, process mapping, and reflective journaling. We evaluated TNP nurse satisfaction and perceived utility of the structure and process of the training and bundle through pre-post surveys. To assess the outcome of data collection efforts, we interviewed nurses 4 months after completion of the pre-implementation assessment to determine if and how they used pre-implementation findings to tailor implementation of TNP to local contexts. To further assess outcomes, all data that the nurses collected were analyzed thematically. Themes related to barriers and facilitators were compared across years. Findings Five nurses at different VA medical centers used the pre-implementation strategy bundle to collect site-level data and completed pre-post surveys. Findings indicated that the pre-implementation assessment was highly recommended, and the bundle provided adequate training. Nurses felt that pre-implementation work oriented them to the local context and illustrated how to integrate TNP into existing processes. Barriers and facilitators identified by nurses were similar to those collected in year 1 by the TNP research team, including communication challenges, need for buy-in, and logistical concerns. Conclusions This proof-of-concept study suggests that evidence-based tools can effectively guide clinician-implementers through the process of conducting a pre-implementation assessment. This approach positively informed TNP implementation and oriented nurses to their local context prior to implementation.

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Engaging Stakeholders to Retrospectively Discern Implementation Strategies in Support of Program Evaluation

10.21203/rs.3.rs-573512/v1 ◽

2021 ◽

Author(s):

Jacob T. Painter ◽

Rebecca A. Raciborski ◽

Monica M. Matthieu ◽

Ciara Oliver ◽

David A. Adkins ◽

...

Keyword(s):

Program Evaluation ◽

Quality Improvement ◽

Data Collection ◽

Implementation Strategy ◽

Implementation Strategies ◽

Successful Implementation ◽

Evidence Based ◽

Main Body ◽

Strategy Selection ◽

Evidence Based Practices

Abstract Background: Successful implementation of evidence-based practices is key to healthcare quality improvement. However, it depends on appropriate selection of implementation strategies, the techniques that improve practice adoption or sustainment. When studying implementation of an evidence-based practice as part of a program evaluation, implementation scientists confront a challenge: the timing of strategy selection rarely aligns with the establishment of data collection protocols. Indeed, the exact implementation strategies used by an organization during a quality improvement initiative may be determined during implementation. Nevertheless, discernment of strategies is necessary to accurately estimate implementation effect and cost because this information can support decision making for sustainment, guide replication efforts, and inform the choice of implementation strategies for other evidence-based practices. Main body: We propose an iterative, stakeholder engaged process to discern implementation strategies when strategy choice was not made before data collection began. Stakeholders are centered in the process, providing a list of current and potential implementation activities. These activities are then mapped by an implementation science expert to an established taxonomy of implementation strategies. The mapping is then presented back to stakeholders for member checking and refinement. The final list can be used to survey those engaged in implementation activities in a language they are familiar with. A case study using this process is provided. Conclusion: It is challenging to estimate implementation effort when implementation strategy selection is disconnected from the data collection process. In these cases, a stakeholder-informed process to retrospectively identify implementation strategies by classifying activities performed using an established implementation strategy taxonomy provides the necessary information.

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Application of the Non-adoption, Abandonment, Scale-up, Spread and, Sustainability (NASSS) Framework to evaluate the role of technology in the Pathways to Comorbidity Care (PCC) implementation project to improve management of comorbid substance use and mental disorders

10.31234/osf.io/t9rs4 ◽

2020 ◽

Author(s):

MariaGabriela Uribe Guajardo ◽

Andrew James Baillie ◽

Eva Louie ◽

Vicki Giannopoulos ◽

Katie Wood ◽

...

Keyword(s):

Substance Use ◽

Clinical Supervision ◽

Mental Health Problems ◽

Scale Up ◽

Structured Interview ◽

Barriers And Facilitators ◽

Self Report ◽

Evidence Based ◽

Face To Face ◽

Drug And Alcohol

Abstract (250 words)In substance use treatment settings, there is a high prevalence of comorbid mental health problems. Yet an integrated approach for managing comorbidity, implementation of evidence-based intervention in drug and alcohol settings remains problematic. Technology can help the adoption of evidence-based practice and successfully implement effective treatment health care pathways. This study sought to examine aspects of electronic resources utilisation (barriers and facilitators) by clinicians participating in the PCC training. MethodA self-report questionnaire and a semi-structured interview was designed to measure overall satisfaction with the PCC portal and e-resources available throughout the 9-month intervention for participating clinicians. An adapted version of the ‘Non-adoption, Abandonment, Scale-up, Spread and, Sustainability’ (NASSS) framework was used to facilitate discussion in regards to the study findings. ResultsA total of 20 clinicians from drug and alcohol services responded to all the measures. Facilitators of portal use included: i. clinician acceptance of the PCC portal; ii. guidance from the clinical supervisor or clinical champion that encouraged the use of e-resources. Some of the barriers included: i. complexity of the illness (condition), ii. clinicians’ preference (adopter system) for face-to-face resources and training modes (e.g. clinical supervision, clinical champion workshops), and iii. lack of face-to-face training on how to use the portal (technology and organisation).ConclusionBased on the NASSS framework, we were able to identify several barriers and facilitators including such as the complexity of the illness, lack of face-to-face training and clinician preference for training mediums. Recommendations include ongoing consultation of clinicians to assist in the development of tailored e-health resources and offering in-house training on how to operate and effectively utilise these resources.

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Developing implementation strategies to adopt Enhanced Recovery After Surgery (ERAS®) guidelines

BJS Open ◽

10.1093/bjsopen/zraa011 ◽

2020 ◽

Vol 5 (2) ◽

Author(s):

Jennifer Y Lam ◽

Alexandra Howlett ◽

Duncan McLuckie ◽

Lori M Stephen ◽

Scott D N Else ◽

...

Keyword(s):

Implementation Strategy ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Healthcare Providers ◽

Implementation Strategies ◽

Multidisciplinary Teams ◽

Successful Implementation ◽

Care Pathways ◽

Audit System ◽

Local Contexts

Abstract Background Strong implementation strategies are critical to the success of Enhanced Recovery after Surgery (ERAS®) guidelines, though little documentation exists on effective strategies, especially in complex clinical situations and unfamiliar contexts. This study outlines the process taken to adopt a novel neonatal ERAS® guideline. Methods The implementation strategy was approached in a multi-pronged, concurrent but asynchronous fashion. Between September 2019 and January 2020, healthcare providers from various disciplines and different specialties as well as parents participated in the strategy. Multidisciplinary teams were created to consider existing literature and local contexts including potential facilitators and/or barriers. Task forces worked collaboratively to develop new care pathways. An audit system was developed to record outcomes and elicit feedback for revision. Results 32 healthcare providers representing 9 disciplines and 5 specialties as well as 8 parents participated. Care pathways and resources were created. Elements recommended for a successful implementation strategy included identification of champions, multidisciplinary stakeholder involvement, consideration of local contexts and insights, patient/family engagement, education, and creation of an audit system. Conclusion A multidisciplinary and structured process following principles of implementation science was used to develop an effective implementation strategy for initiating ERAS® guidelines.

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Planning Implementation Success of Syncope Clinical Practice Guidelines in the Emergency Department Using CFIR Framework

10.20944/preprints202103.0679.v1 ◽

2021 ◽

Author(s):

Jing Li ◽

Susan S. Smyth ◽

Jessica Miller Clouser ◽

Colleen A. McMullen ◽

Vedant Gupta ◽

...

Keyword(s):

Emergency Department ◽

Clinical Practice ◽

Family Caregivers ◽

Implementation Strategy ◽

Care Pathway ◽

Implementation Strategies ◽

Mobile App ◽

Care Plan ◽

Local Context ◽

Successful Implementation

Background and Objectives: Overuse and inappropriate use of testing and hospital admission are common in syncope evaluation and management. Though guidelines are available to optimize syncope care, study suggested that the current clinical guidelines have not significantly impacted resource utilization surrounding emergency department (ED) evaluation of syncope. Matching implementation strategies to barriers and facilitators and tailoring strategies to local context hold significant promise for a successful implementation of clinical practice guideline (CPG). Our team applied implementation science principles to develop a stakeholder-based implementation strategy. Methods and Materials: We partnered with patients, family caregivers, frontline clinicians and staff, and health system administrators at four health systems to conduct quantitative surveys and qualitative interviews for context assessment. The identification of implementation strategies was done by applying the CFIR-ERIC Implementation Strategy Matching Tool and soliciting stakeholders’ inputs. We then co-designed with patients and frontline teams, developed and tested specific strategies. Results: 114 clinicians completed surveys and 32 clinicians and stake-holders participated in interviews. Results from the surveys and interview indicated low awareness of syncope guidelines, and communication challenges with patients, lack of CPG protocol integration into ED workflows, and organizational process to change were recognized as major barriers. Thirty-one patients and their family caregivers participated in interviews and ex-pressed their expectations: clarity regarding their diagnosis, context surrounding care plan and diagnostic testing, and a desire to feel cared about. After identifying change methods to address those barriers, the multilevel, multicomponent implementation strategy, MISSION, included pa-tient educational materials, mentored implementation, academic detailing, Syncope Optimal Care Pathway and corresponding Mobile App, and Lean quality improvement methods. The pilot of MISSION demonstrated feasibility, acceptability and initial success on appropriate testing. Con-clusions: Effect multifaceted implementation strategies that target individuals, teams, and healthcare systems can be employed to plan successful implementation and promote adherence to syncope CPGs.

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Identifying barriers, facilitators, and implementation strategies for a faith-based physical activity program

10.21203/rs.3.rs-16135/v2 ◽

2020 ◽

Author(s):

Jessica Haughton ◽

Michelle L. Takemoto ◽

Jennifer Schneider ◽

Steven P. Hooker ◽

Borsika Rabin ◽

...

Keyword(s):

Physical Activity ◽

Health Promotion ◽

Scale Up ◽

Implementation Strategies ◽

Barriers And Facilitators ◽

Physical Activity Program ◽

Evidence Based ◽

Church Staff ◽

Faith Based ◽

Activity Program

Abstract Background: Community engagement is critical to the acceleration of evidence-based interventions into community settings. Harnessing the knowledge and opinions of community leaders increases the likelihood of successful implementation, scale up, and sustainment of evidence-based interventions. Faith in Action (Fe en Acción) is an evidence-based promotora-led physical activity program designed to increase moderate-to-vigorous physical activity among churchgoing Latina women.Methods: We conducted in-depth interviews using a semi-structured interview guide based on the Consolidated Framework for Implementation Research (CFIR) at various Catholic and Protestant churches with large Latino membership in San Diego County, California to explore barriers and facilitators to implementation of Faith in Action and identify promising implementation strategies for program scale-up and dissemination. We interviewed 22 pastors and church staff and analyzed transcripts using an iterative-deductive team approach. Results: Pastors and church staff described barriers and facilitators to implementation within three domains of CFIR: characteristics of individuals (lack of self-efficacy for and knowledge of physical activity; influence on churchgoers’ behaviors), inner setting (church culture and norms, alignment with mission and values, competing priorities, lack of resources), and outer setting (need for buy-in from senior leadership). From the interviews, we identified four promising implementation strategies for the scale-up of faith-based health promotion programs: 1) health behavior change training for pastors and staff; 2) tailored messaging; 3) developing community collaborations; and 4) gaining denominational support.Conclusions: While churches can serve as valuable partners in health promotion, specific barriers and facilitators to implementation must be recognized and understood. Addressing these barriers through targeted implementation strategies at the adopter and organizational level can facilitate improved program implementation and lead the way for scale-up and dissemination.

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The Tennessee Medicaid medication therapy management program: early stage contextual factors and implementation outcomes

BMC Health Services Research ◽

10.1186/s12913-021-07193-7 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Kenneth C. Hohmeier ◽

Chelsea Renfro ◽

Kea Turner ◽

Parin Patel ◽

Estrella Ndrianasy ◽

...

Keyword(s):

Implementation Strategy ◽

Early Stage ◽

Implementation Strategies ◽

Medication Therapy Management ◽

Barriers And Facilitators ◽

Evidence Based ◽

Pilot Program ◽

Individual Level ◽

Medication Therapy ◽

Implementation Outcomes

Abstract Background First investigated in the 1990s, medication therapy management (MTM) is an evidence-based practice offered by pharmacists to ensure a patient’s medication regimen is individualized to include the safest and most effective medications. MTM has been shown to a) improve quality of patient care, b) reduces health care costs, and c) lead to fewer medication-related adverse effects. However, there has been limited testing of evidence-based, a-priori implementation strategies that support MTM implementation on a large scale. Methods The study has two objectives assessed at the organizational and individual level: 1) to determine the adoption, feasibility, acceptability and appropriateness of a multi-faceted implementation strategy to support the MTM pilot program in Tennessee; and 2) to report on the contextual factors associated with program implementation based on the Consolidated Framework for Implementation Research (CFIR). The overall design of the study was a hybrid type 2 effectiveness-implementation study reporting outcomes of Tennessee state Medicaid’s (TennCare) MTM Pilot program. This paper presents early stage implementation outcomes (e.g., adoption, feasibility, acceptability, appropriateness) and explores implementation barriers and facilitators using the CFIR. The study was assessed at the (a) organizational and (b) individual level. A mixed-methods approach was used including surveys, claims data, and semi-structured interviews. Interview data underwent initial, rapid qualitative analysis to provide real time feedback to TennCare leadership on project barriers and facilitators. Results The total reach of the program from July 2018 through June 2020 was 2033 MTM sessions provided by 17 Medicaid credentialed pharmacists. Preliminary findings suggest participants agreed that MTM was acceptable (μ = 16.22, SD = 0.28), appropriate (μ = 15.33, SD = 0.03), and feasible (μ = 14.72, SD = 0.46). Each of the scales had an excellent level of internal (> 0.70) consistency (feasibility, α = 0.91; acceptability, α = 0.96; appropriateness, α = 0.98;). Eight program participants were interviewed and were mapped to the following CFIR constructs: Process, Characteristics of Individuals, Intervention Characteristics, and Inner Setting. Rapid data analysis of the contextual inquiry allowed TennCare to alter initial implementation strategies during project rollout. Conclusion The early stage implementation of a multi-faceted implementation strategy to support delivery of Tennessee Medicaid’s MTM program was found to be well accepted and appropriate across multiple stakeholders including providers, administrators, and pharmacists. However, as the early stage of implementation progressed, barriers related to relative priority, characteristics of the intervention (e.g., complexity), and workflow impeded adoption. Programmatic changes to the MTM Pilot based on early stage contextual analysis and implementation outcomes had a positive impact on adoption.

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What hinders and facilitates the implementation of nurse-led interventions in dementia care? A scoping review

10.21203/rs.2.20304/v2 ◽

2020 ◽

Author(s):

Melanie Karrer ◽

Julian Hirt ◽

Adelheid Zeller ◽

Susi Saxer

Keyword(s):

Scoping Review ◽

Implementation Process ◽

Dementia Care ◽

Barriers And Facilitators ◽

Successful Implementation ◽

Evidence Based ◽

Management Support ◽

Implementation Processes ◽

Culture Of Care ◽

People With Dementia

Abstract Background The implementation of evidence-based interventions for people with dementia is complex and challenging. However, successful implementation might be a key element to ensure evidence-based practice and high quality of care. There is a need to improve implementation processes in dementia care by better understanding the arising challenges. Thus, the aim of this study was to identify recent knowledge concerning barriers and facilitators to implementing nurse-led interventions in dementia care. Methods We performed a scoping review using the methodological framework of Arksey and O’Malley. Studies explicitly reporting on the implementation process and factors influencing the implementation of a nurse-led intervention in dementia care in all settings were included. We searched eight databases from January 2015 until January 2019. Two authors independently selected the studies. For data analysis, we used an inductive approach to build domains and categories. Results We included 26 studies in the review and identified barriers as well as facilitators in five domains: policy (e.g. financing issues, health insurance), organisation (e.g. organisational culture and vision, resources, management support), intervention/implementation (e.g. complexity of the intervention, perceived value of the intervention), staff (e.g. knowledge, experience and skills, attitude towards the intervention), and person with dementia/family (e.g. nature and stage of dementia, response of persons with dementia and their families). Conclusions Besides general influencing factors for implementing nursing interventions, we identified dementia-specific factors reaching beyond already known barriers and facilitators. A pre-existing person-centred culture of care as well as consistent team cultures and attitudes have a facilitating effect on implementation processes. Furthermore, there is a need for interventions that are highly flexible and sensitive to patients’ condition, needs and behaviour.

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Engaging stakeholders to identify implementation strategies for a faith-based physical activity program

10.21203/rs.2.23928/v1 ◽

2020 ◽

Author(s):

Jessica Haughton ◽

Michelle L. Takemoto ◽

Jennifer Schneider ◽

Steven P. Hooker ◽

Borsika Rabin ◽

...

Keyword(s):

Physical Activity ◽

Health Promotion ◽

Scale Up ◽

Implementation Strategies ◽

Health Behavior Change ◽

Barriers And Facilitators ◽

Physical Activity Program ◽

Evidence Based ◽

Faith Based ◽

Activity Program

Abstract Background Stakeholder engagement is critical to the acceleration of evidence-based interventions into community settings. Harnessing the knowledge and opinions of community stakeholders increases the likelihood of successful implementation, scale up, and sustainment of evidence-based interventions. Faith in Action ( Fe en Acción ) is an evidence-based promotora -led physical activity program designed to increase moderate-to-vigorous physical activity among churchgoing Latina women. Methods We conducted in-depth interviews using a semi-structured interview guide based on the Consolidated Framework for Implementation Research (CFIR) at various Catholic and Protestant churches with large Latino membership in San Diego County, California to explore barriers and facilitators to implementation of a Faith in Action and to identify promising implementation strategies for program scale-up and dissemination. We interviewed 22 pastors and church staff and analyzed transcripts using an iterative-deductive team approach. Results Stakeholders described barriers and facilitators to implementation within three domains of CFIR: characteristics of individuals (lack of self-efficacy for and knowledge of PA; influence on churchgoers’ behaviors), inner setting (church culture and norms, alignment with mission and values, competing priorities, lack of resources), and outer setting (need for buy-in from senior leadership). From the interviews, we identified four promising implementation strategies for the scale-up of faith-based health promotion programs: 1) health behavior change training for pastors and staff; 2) tailored messaging; 3) developing community collaborations; and 4) gaining denominational support. Conclusions While churches can serve as valuable partners in health promotion, specific barriers and facilitators to implementation must be recognized and understood. Addressing these barriers through targeted implementation strategies at the adopter and organizational level can facilitate improved program implementation and lead the way for scale-up and dissemination.

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Engaging stakeholders to identify implementation strategies for a faith-based physical activity program

10.21203/rs.3.rs-16135/v1 ◽

2020 ◽

Author(s):

Jessica Haughton ◽

Michelle L. Takemoto ◽

Jennifer Schneider ◽

Steven P. Hooker ◽

Borsika Rabin ◽

...

Keyword(s):

Physical Activity ◽

Health Promotion ◽

Scale Up ◽

Implementation Strategies ◽

Health Behavior Change ◽

Barriers And Facilitators ◽

Physical Activity Program ◽

Evidence Based ◽

Faith Based ◽

Activity Program

Abstract Background: Stakeholder engagement is critical to the acceleration of evidence-based interventions into community settings. Harnessing the knowledge and opinions of community stakeholders increases the likelihood of successful implementation, scale up, and sustainment of evidence-based interventions. Faith in Action ( Fe en Acción ) is an evidence-based promotora -led physical activity program designed to increase moderate-to-vigorous physical activity among churchgoing Latina women.Methods: We conducted in-depth interviews using a semi-structured interview guide based on the Consolidated Framework for Implementation Research (CFIR) at various Catholic and Protestant churches with large Latino membership in San Diego County, California to explore barriers and facilitators to implementation of a Faith in Action and to identify promising implementation strategies for program scale-up and dissemination. We interviewed 22 pastors and church staff and analyzed transcripts using an iterative-deductive team approach.Results: Stakeholders described barriers and facilitators to implementation within three domains of CFIR: characteristics of individuals (lack of self-efficacy for and knowledge of PA; influence on churchgoers’ behaviors), inner setting (church culture and norms, alignment with mission and values, competing priorities, lack of resources), and outer setting (need for buy-in from senior leadership). From the interviews, we identified four promising implementation strategies for the scale-up of faith-based health promotion programs: 1) health behavior change training for pastors and staff; 2) tailored messaging; 3) developing community collaborations; and 4) gaining denominational support.Conclusions: While churches can serve as valuable partners in health promotion, specific barriers and facilitators to implementation must be recognized and understood. Addressing these barriers through targeted implementation strategies at the adopter and organizational level can facilitate improved program implementation and lead the way for scale-up and dissemination.

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

10.21203/rs.3.rs-711452/v1 ◽

2021 ◽

Author(s):

Jieya Yue ◽

Jun Liu ◽

Yingxi Zhao ◽

Sarah Williams ◽

Bo Zhang ◽

...

Keyword(s):

Scale Up ◽

Improve Patient Care ◽

Successful Implementation ◽

Evidence Based ◽

Hospital Level ◽

Structured Interviews ◽

Knowledge And Beliefs ◽

Tertiary Hospitals ◽

Parihs Framework ◽

Study Participants

Abstract 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. To gain an understanding of the utility of the PARIHS framework in China and investigate how important each of its constructs (evidence, context and facilitation) and sub-elements are perceived to be to successful implementation of EBIs in a Chinese setting, we used the framework to assess the implementation of an evidence-based neonatal intervention (kangaroo mother care, KMC) recently introduced in selected Chinese hospitals. 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 Our finding suggest that clinical experience, culture, leadership, evaluation, and facilitation are highly influential sub-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 The PHARIS 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.

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