Contextual Influences Experienced by Queensland Midwives: A Qualitative Study Focusing on Alcohol and Other Substance Use During Pregnancy

PURPOSETo understand the experiences and contextual factors that influence the ability of midwives to provide appropriate support to women regarding alcohol and other drug (AOD)e use during pregnancy, in the Queensland context.DESIGNUsing a qualitative approach underpinned by critical realism, we explored the experiences of eleven midwives using semi-structured interviews. Thematic analysis was utilized, which was inductive and deductive, as it aimed to explicate different contextual factors at play, based on the experiences of the current sample of midwives.MAJOR FINDINGSExperiences of midwives in the current study were influenced by five overarching contextual factors: (a) patient-level factors (complexities experienced by women and lack of knowledge regarding maternity care options); (b) provider/patient-level factors (importance of midwives building relationships with women and importance of continuity of care); (c) provider-level factors (importance of taking a supportive approach, midwife confidence, engagement in AOD screening, variable attitudes and knowledge); (d) organizational-level factors (lack of support and training, concerns regarding communication, time constraints and organizations that limited midwife involvement); (e) broader system-level factors (lack of effective services and inconsistent messages regarding AOD use during pregnancy).CONCLUSIONSThe current study has highlighted a range of practice areas and potential implementation strategies across a number of contextual levels that could be beneficial in the Queensland context to improve maternity care provision for women who are experiencing AOD use challenges during pregnancy.

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GPs’ involvement in diagnosing, treating, and referring patients with suspected or confirmed primary cutaneous melanoma: a qualitative study

BJGP Open ◽

10.3399/bjgpopen20x101028 ◽

2020 ◽

Vol 4 (2) ◽

pp. bjgpopen20X101028

Author(s):

Andrea L Smith ◽

Caroline G Watts ◽

Samuel Robinson ◽

Helen Schmid ◽

Chiao-Han Chang ◽

...

Keyword(s):

Skin Cancer ◽

Melanoma Patient ◽

Lymph Node Biopsy ◽

System Level ◽

Structured Interviews ◽

Primary Cutaneous Melanoma ◽

Patient Level ◽

Multiple Factors ◽

Factors Influencing ◽

Node Biopsy

BackgroundIn Australia, melanoma is managed in primary and secondary care settings. An individual concerned about a suspicious lesion typically presents first to their GP.AimTo identify factors influencing GPs’ decisions to diagnose, treat, or refer patients with suspected melanoma.Design & settingSemi-structured interviews were undertaken with 23 GPs working in general practice or skin cancer clinics in Australia.MethodThe semi-structured interviews were audio-recorded, de-identified, and professionally transcribed. Thematic analysis was used to analyse the data.ResultsConsiderable variation existed in GPs’ self-reported confidence and involvement in melanoma management. Multiple factors were identified as influencing GPs’ decisions to diagnose, treat, or refer patients with suspected or confirmed melanoma. Health system level factors included the overlapping roles of GPs and specialists, and access to and/or availability of specialists. Practice level factors included opportunities for formal and informal training, and having a GP with a special interest in skin cancer within their practice. GP and patient level factors included the GP’s clinical interests, the clinical features (for example, site and size) and histopathology of the suspected melanoma, eligibility for possible sentinel lymph node biopsy, and patient preferences. For some GPs, concerns over misdiagnosis and the option of referring patients at any stage in the melanoma management continuum appeared to affect their interest and confidence in melanoma management.ConclusionGP involvement in melanoma patient care can extend well beyond cancer screening, prevention and supportive care roles to include provision of definitive melanoma patient management. GPs with an interest in being involved in melanoma management should be encouraged and supported to develop the skills needed to manage these patients, and to refer when appropriate.

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Study protocol of a co-created primary organizational-level intervention with the aim to improve organizational and social working conditions and decrease stress within the construction industry – a controlled trial

BMC Public Health ◽

10.1186/s12889-020-08542-7 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Emma Cedstrand ◽

Anna Nyberg ◽

Theo Bodin ◽

Hanna Augustsson ◽

Gun Johansson

Keyword(s):

Construction Industry ◽

Working Conditions ◽

Controlled Trial ◽

Implementation Strategies ◽

Readiness For Change ◽

Organizational Level ◽

Physical Work ◽

Control Group ◽

Role Clarity ◽

Structured Interviews

Abstract Background Within construction industry, physical work exposures have long been recognized as possible determinants for musculoskeletal disorders, but less attention has been given the increasing organizational and social work hazards and stress within this industry. There is to date a lack of knowledge about how to improve organizational and social working conditions and decrease stress within the construction industry. Methods This paper outlines the design of a controlled trial to evaluate the effectiveness of a co-created organizational-level intervention with the aim to improve role clarity, quantitative demands, staffing, planning, team effectiveness, psychosocial safety climate and stress. Two regions (> 700 employees) within one large construction company in Sweden will participate as intervention and control group. Further we present the design of the process evaluation assessing fidelity, support from managers, readiness for change and contextual factors. We will utilize questionnaires, semi-structured interviews, observations and documentation as means for data collection, hence a mixed methods approach is applied. Discussion The study is expected to contribute to the understanding of how adverse organizational and social working conditions and stress can be improved within the construction industry. By applying co-creation we wish to develop an intervention and implementation strategies that fit to the context, are in line with the needs of end-users and are supported by all management levels - all of which are highlighted features in successful workplace interventions. Trial registration ISRCTN, ISRCTN16548039. Registered 12/02/20. Retrospectively registered

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Implementing lateral flow devices in long-term care facilities: experiences from the Liverpool COVID-19 community testing pilot in care homes— a qualitative study

BMC Health Services Research ◽

10.1186/s12913-021-07191-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Patrick Kierkegaard ◽

Massimo Micocci ◽

Anna McLister ◽

John S. P. Tulloch ◽

Paula Parvulescu ◽

...

Keyword(s):

Real World ◽

Test Performance ◽

Contextual Factors ◽

Implementation Strategies ◽

Lateral Flow ◽

Routine Practice ◽

Structured Interviews ◽

Term Care ◽

The Real ◽

Flow Devices

Abstract Introduction Antigen-based lateral flow devices (LFDs) offer the potential of widespread rapid testing. The scientific literature has primarily focused on mathematical modelling of their use and test performance characteristics. For these tests to be implemented successfully, an understanding of the real-world contextual factors that allow them to be integrated into the workplace is vital. To address this gap in knowledge, we aimed to explore staff’s experiences of integrating LFDs into routine practice for visitors and staff testing with a view to understand implementation facilitators and barriers. Methods Semi-structured interviews and thematic analysis. Results We identified two main themes and five subthemes. The main themes included: visitor-related testing factors and staff-related testing factors. Subthemes included: restoring a sense of normality, visitor-related testing challenges, staff-related testing challenges, and pre-pilot antecedent factors. Conclusion Our study demonstrates that the real-world implementation of LFDs to test visitors and staff faces significant challenges as a result of several contextual factors negatively affecting the work practice and environment. More comprehensive studies are needed to identify and inform effective implementation strategies to ensure that LFDs can be adopted in an agile way that better supports an already exhausted and morally depleted workforce.

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Rationale and protocol for a cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment rates for cancer patients who smoke

Implementation Science ◽

10.1186/s13012-021-01139-7 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Brian P. Jenssen ◽

Robert Schnoll ◽

Rinad Beidas ◽

Justin Bekelman ◽

Anna-Marika Bauer ◽

...

Keyword(s):

Tobacco Use ◽

Cancer Care ◽

Contextual Factors ◽

Treatment Engagement ◽

Implementation Strategies ◽

Secondary Outcome ◽

Evidence Based ◽

Structured Interviews ◽

Behavioral Economic ◽

Cluster Randomized

Abstract Background Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care. Methods A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or “nudges”) promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges. Discussion This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers. Trial registration Clinicaltrials.gov, NCT04737031. Registered 3 February 2021.

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Behavioral Economic Implementation Strategies to Improve Serious Illness Communication Between Clinicians and High-risk Patients With Cancer: Protocol for a Cluster Randomized Pragmatic Trial

10.21203/rs.3.rs-835396/v1 ◽

2021 ◽

Author(s):

Samuel U. Takvorian ◽

Justin Bekelman ◽

Rinad S. Beidas ◽

Robert Schnoll ◽

Alicia B.W. Clifton ◽

...

Keyword(s):

High Risk ◽

Contextual Factors ◽

Pragmatic Trial ◽

Implementation Strategies ◽

Structured Interviews ◽

Serious Illness ◽

High Risk Patients ◽

Patients With Cancer ◽

Risk Patients ◽

Cluster Randomized

Abstract BackgroundSerious illness conversations (SICs) are an evidence-based approach to eliciting patients’ values, goals, and care preferences that improve patient outcomes. However, most patients with cancer die without a documented SIC. Clinician-directed implementation strategies informed by behavioral economics (“nudges”) that identify high-risk patients have shown promise in increasing SIC documentation among clinicians. It is unknown whether patient-directed nudges that normalize and prime patients towards SIC completion—either alone or in combination with clinician nudges that additionally compare performance relative to peers—may improve on this approach. Our objective is to test the effect of clinician- and patient-directed nudges as implementation strategies for increasing SIC completion among patients with cancer. MethodsWe will conduct a 2x2 factorial, cluster randomized pragmatic trial to test the effect of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Participants will include 166 medical and gynecologic oncology clinicians practicing at ten sites within a large academic health system, and their approximately 5,500 patients at high risk of predicted 6-month mortality based on a validated machine-learning prognostic algorithm. Data will be obtained via the electronic medical record, clinician survey, and semi-structured interviews with clinicians and patients. The primary outcome will be time to SIC documentation among high-risk patients. Secondary outcomes will include time to SIC documentation among all patients (assessing spillover effects); palliative care referral among high-risk patients; and aggressive end-of-life care utilization (composite of chemotherapy within 14 days before death, hospitalization within 30 days before death, or admission to hospice within 3 days before death) among high-risk decedents. We will assess moderators of the effect of implementation strategies, and conduct semi-structured interviews with a subset of clinicians and patients to assess contextual factors that shape effectiveness of nudges with an eye towards health equity.DiscussionThis will be the first pragmatic trial to evaluate clinician- and patient-directed nudges to promote SIC completion for patients with cancer. We expect the study to yield insights into the effectiveness of clinician and patient nudges as implementation strategies to improve SIC rates, and to uncover multilevel contextual factors that drive response to these strategies.Trial registrationClinicaltrials.gov, NCT04867850. Registered April 30, 2021. https://clinicaltrials.gov/ct2/show/NCT04867850?term=serious+illness&draw=2&rank=3

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Context: a key dimension in midwifery decision making and practice for safe labour care

African Journal of Midwifery and Women s Health ◽

10.12968/ajmw.2019.0035 ◽

2020 ◽

Vol 14 (3) ◽

pp. 1-14

Author(s):

Elizabeth Chodzaza ◽

Elaine Haycock-Stuart ◽

Aisha Holloway ◽

Ursula Kafulafula

Keyword(s):

Decision Making ◽

Maternity Care ◽

Clinical Decision Making ◽

Medical Profession ◽

Contextual Factors ◽

Real Life ◽

Clinical Decision ◽

Structured Interviews ◽

Theoretical Understanding ◽

The Real

Background/Aims Research into midwifery decision making to date is limited and, where it exists, theoretical understanding has focused on the cognitive aspects of the process. Understanding the real-life context in which midwives work and how this influences their decision making during labour is important for safer maternity care. This study aimed to explore the contextual factors that influence the decision making of midwives at secondary and tertiary level health facilities during the first stage of labour in the real context of practice. Methods Using a focused ethnographic methodology, data from nine midwives working in two hospital labour ward settings were collected from October 2013 to May 2014. A total of 27 participant observations of midwives supporting women in the first stage of labour, 26 semi-structured interviews with midwives, and a documentary analysis of maternal labour records were conducted. All data were analysed using theme and category formation. Results Four major themes that influenced midwifery decision making for the safe care of women in labour were found: dominance of the medical profession over maternity care, shortage of midwifery staff, limited material resources, and midwifery strategies for maternal and child safety. Conclusions Understanding and improving clinical decision making requires consideration of contextual factors. For safe maternal care during the first stage of labour, midwives need to be supported to manage contextual factors for favourable outcomes for the mother and neonate.

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Patient Perspectives on the Implementation of Risk-Aligned Bladder Cancer Surveillance: Systematic Evaluation Using the Tailored Implementation for Chronic Diseases Framework

JCO Oncology Practice ◽

10.1200/jop.19.00576 ◽

2020 ◽

Vol 16 (8) ◽

pp. e668-e677

Author(s):

Florian R. Schroeck ◽

Amanda St Ivany ◽

William Lowrance ◽

Danil V. Makarov ◽

Philip P. Goodney ◽

...

Keyword(s):

Bladder Cancer ◽

Cancer Risk ◽

Chronic Diseases ◽

Implementation Strategies ◽

Cancer Surveillance ◽

System Level ◽

Systematic Evaluation ◽

Risk Category ◽

Patient Level ◽

Tailored Implementation

PURPOSE: Many patients living with bladder cancer do not undergo surveillance that is aligned with their risk for recurrence or progression, which exposes them to unnecessary risk and burden of procedures. To implement risk-aligned surveillance as recommended by multiple guidelines, we need to understand patient-, provider-, and system-level factors contributing to the delivery of risk-aligned surveillance. In this study, we sought to systematically assess patient-level factors. PARTICIPANTS AND METHODS: Guided by the Tailored Implementation for Chronic Diseases framework, we conducted semistructured interviews with 22 patients with bladder cancer undergoing surveillance cystoscopy procedures at three facilities within the Department of Veterans Affairs. Patients were sampled using quantitative data on bladder cancer risk category (low v high) and on surveillance category (aligned v not aligned with cancer risk). Interview transcripts were analyzed using a priori codes from the Tailored Implementation for Chronic Diseases framework. Quantitative and qualitative data were integrated by cross-tabulating determinants across risk and surveillance categories. RESULTS: Participants included seven low-risk and 15 high-risk patients; 10 underwent risk-aligned surveillance and 12 did not. In mixed-methods analyses, perception of risk appropriately differed by risk but not by surveillance category. Participants understood the recommended surveillance schedule according to their risk category. Participants emphatically expressed that adhering to providers’ recommendations is prudent; intentions to adhere did not vary across risk and surveillance categories. CONCLUSION: Participants intended to adhere to providers’ recommendations and strongly endorsed the importance of adherence. These findings suggest implementation strategies to improve risk-aligned surveillance may be most effective when targeting provider- and system-level factors rather than patient-level factors.

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The Role of Leadership in Organizational Implementation and Sustainment in Service Agencies

Research on Social Work Practice ◽

10.1177/1049731517718361 ◽

2017 ◽

Vol 28 (5) ◽

pp. 558-567 ◽

Cited By ~ 7

Author(s):

Joanna C. Moullin ◽

Mark G. Ehrhart ◽

Gregory A. Aarons

Keyword(s):

Organizational Climate ◽

Implementation Strategies ◽

System Level ◽

Organizational Level ◽

Unique Combination ◽

Collaborative Relationships ◽

General Consensus ◽

Critical Issues ◽

Service Agencies

Implementation is posited as a multiphasic process, influenced by a range of factors, within a multilevel context. While there appears to be a general consensus that every implementation initiative will have a unique combination of influences that vary in importance across the implementation phases, leadership is an essential tenant throughout implementation frameworks, models, and theories. The exploration, preparation, implementation, sustainment framework is used to explore leadership, at both the inner organizational level and the outer system level, and to guide a discussion regarding three critical issues involved in implementation (organizational climate/culture, collaborative relationships, and contracting). Finally, three implementation strategies focused on improving leadership are described in order to provide examples of these issues.

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Behavioral economic implementation strategies to improve serious illness communication between clinicians and high-risk patients with cancer: protocol for a cluster randomized pragmatic trial

Implementation Science ◽

10.1186/s13012-021-01156-6 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Samuel U. Takvorian ◽

Justin Bekelman ◽

Rinad S. Beidas ◽

Robert Schnoll ◽

Alicia B. W. Clifton ◽

...

Keyword(s):

High Risk ◽

Contextual Factors ◽

Pragmatic Trial ◽

Implementation Strategies ◽

Structured Interviews ◽

Serious Illness ◽

High Risk Patients ◽

Patients With Cancer ◽

Risk Patients ◽

Cluster Randomized

Abstract Background Serious illness conversations (SICs) are an evidence-based approach to eliciting patients’ values, goals, and care preferences that improve patient outcomes. However, most patients with cancer die without a documented SIC. Clinician-directed implementation strategies informed by behavioral economics (“nudges”) that identify high-risk patients have shown promise in increasing SIC documentation among clinicians. It is unknown whether patient-directed nudges that normalize and prime patients towards SIC completion—either alone or in combination with clinician nudges that additionally compare performance relative to peers—may improve on this approach. Our objective is to test the effect of clinician- and patient-directed nudges as implementation strategies for increasing SIC completion among patients with cancer. Methods We will conduct a 2 × 2 factorial, cluster randomized pragmatic trial to test the effect of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Participants will include 166 medical and gynecologic oncology clinicians practicing at ten sites within a large academic health system and their approximately 5500 patients at high risk of predicted 6-month mortality based on a validated machine-learning prognostic algorithm. Data will be obtained via the electronic medical record, clinician survey, and semi-structured interviews with clinicians and patients. The primary outcome will be time to SIC documentation among high-risk patients. Secondary outcomes will include time to SIC documentation among all patients (assessing spillover effects), palliative care referral among high-risk patients, and aggressive end-of-life care utilization (composite of chemotherapy within 14 days before death, hospitalization within 30 days before death, or admission to hospice within 3 days before death) among high-risk decedents. We will assess moderators of the effect of implementation strategies and conduct semi-structured interviews with a subset of clinicians and patients to assess contextual factors that shape the effectiveness of nudges with an eye towards health equity. Discussion This will be the first pragmatic trial to evaluate clinician- and patient-directed nudges to promote SIC completion for patients with cancer. We expect the study to yield insights into the effectiveness of clinician and patient nudges as implementation strategies to improve SIC rates, and to uncover multilevel contextual factors that drive response to these strategies. Trial registration ClinicalTrials.gov, NCT04867850. Registered on April 30, 2021. Funding National Cancer Institute P50CA244690

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Drivers of Broad-Spectrum Antibiotic Overuse across Diverse Hospital Contexts—A Qualitative Study of Prescribers in the UK, Sri Lanka and South Africa

Antibiotics ◽

10.3390/antibiotics10010094 ◽

2021 ◽

Vol 10 (1) ◽

pp. 94

Author(s):

Carolyn Tarrant ◽

Andrew M. Colman ◽

David R. Jenkins ◽

Edmund Chattoe-Brown ◽

Nelun Perera ◽

...

Keyword(s):

South Africa ◽

Sri Lanka ◽

Antimicrobial Stewardship ◽

Broad Spectrum ◽

Low Income ◽

System Level ◽

Comparative Approach ◽

Structured Interviews ◽

Public And Private ◽

The Uk

Antimicrobial stewardship programs focus on reducing overuse of broad-spectrum antibiotics (BSAs), primarily through interventions to change prescribing behavior. This study aims to identify multi-level influences on BSA overuse across diverse high and low income, and public and private, healthcare contexts. Semi-structured interviews were conducted with 46 prescribers from hospitals in the UK, Sri Lanka, and South Africa, including public and private providers. Interviews explored decision making about prescribing BSAs, drivers of the use of BSAs, and benefits of BSAs to various stakeholders, and were analyzed using a constant comparative approach. Analysis identified drivers of BSA overuse at the individual, social and structural levels. Structural drivers of overuse varied significantly across contexts and included: system-level factors generating tensions with stewardship goals; limited material resources within hospitals; and patient poverty, lack of infrastructure and resources in local communities. Antimicrobial stewardship needs to encompass efforts to reduce the reliance on BSAs as a solution to context-specific structural conditions.

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