Methodology issues in implementation science

A Qualitative Force Field Analysis of Facilitators and Barriers to Evidence-Based Practice in Healthcare Using an Implementation Framework

Research has identified facilitators and barriers to implementation of evidence-based practices (EBPs). Few studies have evaluated which factors persist among healthcare clinicians with extensive education and training on EBP implementation. Therefore, the purpose of this study was to examine facilitators and barriers to EBP implementation across a national sample of specialty-prepared EBP mentors in healthcare settings. Healthcare clinicians participating in an immersive 5-day EBP knowledge and skill building program were invited to complete a follow-up survey 12 months later to report on implementation experiences. The Consolidated Framework for Implementation Research (CFIR) guided content analysis of responses. A force field analysis using Lewin’s change theory was used to assign numerical ‘weights’ to factors. Eighty-four individuals reported facilitators and barriers to implementation. The majority occurred within the inner setting of the CFIR model. Facilitators were strong leadership engagement (n = 15), positive EBP culture (n = 9), and resources (n = 4). Barriers included lack of resources (n = 21), poor leadership engagement (n = 19), implementation climate (n = 17), lack of relative priority (n = 12), and organizational characteristics (n = 9). Respondents also identified simultaneous facilitators and barriers within the process domain of the CFIR model. The construct of stakeholder engagement was a barrier when absent from the implementation process (n = 23), yet was a strong facilitator when present (n = 23). Implementation in healthcare settings appears most effective when conducted by an interprofessional team with strong leadership, resources, stakeholder engagement, and positive EBP culture. When these same factors are absent, they remain persistent barriers to implementation, even among specialty-trained healthcare clinicians.

Implementation science in adolescent healthcare research: an integrative review

Background

Multiple theories, models and frameworks have been developed to assist implementation of evidence-based practice. However, to date there has been no review of implementation literature specific to adolescent healthcare. This integrative review therefore aimed to determine what implementation science theories, models and frameworks have been applied, what elements of these frameworks have been identified as influential in promoting the implementation and sustainability of service intervention, and to what extent, in what capacity and at what time points has the contribution of adolescent consumer perspectives on evidence implementation been considered. 

Methods

An integrative design was used and reported based on a modified form of the PRISMA (2020) checklist. Seven databases were searched for English language primary research which included any implementation science theory, model or framework developed for/with adolescents or applied in relation to adolescent healthcare services within the past 10 years. Content and thematic analysis were applied with the Consolidated Framework for Implementation Research (CFIR) used to frame analysis of the barriers and facilitators to effective implementation of evidence-informed interventions within youth health settings.

Results

From 8717 citations, 13 papers reporting 12 studies were retained. Nine different implementation science theories, frameworks or approaches were applied; six of 12 studies used the CFIR, solely or with other models. All CFIR domains were represented as facilitators and barriers for implementation in included studies. However, there was little or no inclusion of adolescents in the development or review of these initiatives. Only three mentioned youth input, occurring in the pre-implementation or implementation stages.

Conclusions

The few studies found for this review highlight the internationally under-developed nature of this topic. Flagging the importance of the unique characteristics of this particular age group, and of the interventions and strategies to target it, the minimal input of adolescent consumers is cause for concern. Further research is clearly needed and must ensure that youth consumers are engaged from the start and consistently throughout; that their voice is prioritised and not tokenistic; that their contribution is taken seriously. Only then will age-appropriate evidence implementation enable innovations in youth health services to achieve the evidence-based outcomes they offer.

Trial Registration

PROSPERO 2020 CRD42020201142 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=201142

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07941-3.

Implementation Science to Improve Quality of Neurological Care

Neurological disorders are the leading cause of disability and the second leading cause of death globally. To challenge this enormous disease burden, scientists are pursuing innovative solutions to maintain and improve the quality of neurological care. Despite the availability of many effective evidence-based practices, many patients with neurological disorders cannot access these (or receive them inefficiently after a long delay) and may be exposed to unnecessary, expensive, and potentially harmful treatments. To promote the systematic uptake of evidence-based practices into the real world, a new scientific study of methods has been developed: implementation science. In implementation science research, transdisciplinary research teams systematically (using theory, model, and framework) assess local barriers to facilitate the adoption of evidence-based practices and examine potential solutions using implementation strategies (interventions that help adoption of intended practices) targeting multiple levels in the health care system, including patient, provider, clinic, facility, organization, or broader community and policy environment. The success of these strategies (implementation outcomes) is measured by the extent and quality of the implementation. Implementation studies can be either observational or interventional but are distinct from traditional efficacy or effectiveness studies. Traditional neuroscience research and clinical trials, conducted in controlled settings, focus on discovering new insights with little consideration of translating those insights into the everyday practice of a resource-constrained and dynamic health care system. Thus, neurologists should become familiar with implementation science to reduce the knowledge-practice gap, maximize health care value, and improve management of brain disorders affecting public health.

Exploring the reporting standards of RCTs involving invasive procedures for assisted vaginal birth: A systematic review

OBJECTIVE

Assisted vaginal birth (AVB) is a complex intervention involving medical devices, comprising multiple components. This complexity creates difficulties when designing and conducting randomised controlled trials (RCTs), in terms of describing, standardising and monitoring the intervention, and accounting for differing clinician expertise. This review examines the reporting standards of complex interventions involving a medical device, in the context of AVB RCTs.

STUDY DESIGN

Searches were undertaken from the start of indexing to March 2021, and limited to RCTs, feasibility and pilot studies including at least one device for AVB. RCTs were selected if they included participants having an AVB with any device, with or without a comparator group. Reporting details were assessed according to the Consolidating Standards of Reporting Trials extension for non-pharmacological treatments (CONSORT-NPT), focusing on intervention descriptions, standardization, adherence and clinician expertise. Screening of abstracts, full-text articles and data extraction was performed by two independent reviewers.

RESULTS

Of 4098 abstracts and 83 full-text articles, 39 papers were included, investigating 80 interventions. Twenty-seven different named devices were identified. Intervention descriptions were provided in 20 (55%) papers with varying levels of detail and with only one covering the entire procedure. Standardization of interventions was mentioned in 25 papers (64%). Only eight (21%) papers reported any form of adherence to the intended procedure. Some data regarding expertise were reported in 25 (64%) papers.

CONCLUSIONS

Despite some compliance with reporting standards, there is a lack of detail regarding intervention description, standardization, adherence and expertise in RCTs of AVB. This creates difficulties in understanding how intervention delivery was intended and what actually occurred. Clearer guidelines for the reporting of invasive procedures and devices are required.

Preparing Nursing Contexts for Evidence-Based Practice Implementation: Where Should We Go From Here?

BACKGROUND

Context is important to the adoption and sustainability of evidence-based practices (EBPs). Currently, most published implementation efforts address context in relation to one specific EBP or a bundle of related EBPs. Since EBP and implementation are ongoing and dynamic, more discussion is needed on preparing nursing contexts to be more conducive to implementation generally.

AIM

To discuss the need to create contexts that are more adaptable to ongoing change due to the dynamic nature of EBPs and the ever-changing healthcare environment.

METHODS

This paper builds on a collection of our previous work, as nursing implementation scientists representing the Canadian and American healthcare contexts, and a literature review of the implementation science, knowledge translation, and sustainability literatures from 2006 to 2019.

RESULTS

We argue for a different way of thinking about the influence of context and implementation of EBPs. We contend that nursing contexts must be prepared to be more flexible and conducive to ongoing EBP implementation more generally. Contexts that embrace, facilitate, and have the capacity for change may be more likely to effectively de-implement ineffective interventions or implement and sustain new EBPs. We outline future directions to build a program of research on preparing the soil for implementation of EBPs, including building capacity among nurses, supporting organizations to embrace change, co-producing research evidence, and contributing to implementation science.

LINKING EVIDENCE TO ACTION

Supporting contexts to adopt and sustain evidence in nursing practice is essential for bridging the evidence to practice gap and improving outcomes for patients, clinicians, and the health system. Moving forward, we need to develop a better understanding of how to create contexts that embrace change prior to the implementation of EBPs in order sustain improvements to patient and health system outcomes.

A scoping review of the use of ethnographic approaches in implementation research and recommendations for reporting

BACKGROUND

Researchers have argued for the value of ethnographic approaches to implementation science (IS). The contested meanings of ethnography pose challenges and possibilities to its use in IS. The goal of this study was to identify sources of commonality and variation, and to distill a set of recommendations for reporting ethnographic approaches in IS.

METHODS

We included in our scoping review English-language academic journal articles meeting two criteria: (1) IS articles in the healthcare field and (2) articles that described their approach as ethnographic. In March 2019, we implemented our search criteria in four academic databases and one academic journal. Abstracts were screened for inclusion by at least two authors. We iteratively develop a codebook for full-text analysis and double-coded included articles. We summarized the findings and developed reporting recommendations through discussion.

RESULTS

Of the 210 articles whose abstracts were screened, 73 were included in full-text analysis. The number of articles increased in recent years. Ethnographic approaches were used within a wide variety of theoretical approaches and research designs. Articles primarily described using interviews and observational methods as part of their ethnographic approaches, though numerous other methods were also employed. The most cited rationales for using ethnographic approaches were to capture context-specific phenomena, understand insiders' perspective, and study complex interactions. In reporting on ethnographic approaches, we recommend that researchers provide information on researcher training and position, reflect on researchers' positionality, describe observational methods in detail, and report results from all the methods used.

CONCLUSION

The number of IS studies using ethnography has increased in recent years. Ethnography holds great potential for contributing further to IS, particularly to studying implementation strategy mechanisms and understanding complex adaptive systems.

Implementation of a national mental health intervention in educational communities: What do successful teams do differently?

This study aimed to identify the elements that characterize local teams which implement a nationwide preventive mental health intervention in schools and achieve better results. A mixed-methods sequential explanatory design was conducted in two phases: (a) teams were characterized according to their level of achievement in the preventive intervention through latent class analysis; and (b) case studies of three teams with different implementation results were conducted by performing content analysis on interviews, observations, and documents. It was established that the more effective teams have better planning, the more they are familiar with the intervention, and more aware of their strengths and weaknesses. This team also implement culturally pertinent actions aimed at increasing knowledge about the intervention, which causes schools to experience it as part of their community, since they include the intervention in their regular dynamics. Lastly, the importance and relevance of these elements when working in educational communities is discussed.

Interprofessional Collaboration and Involvement of Parents in the Management of Painful Procedures in Newborns

Introduction: Newborns are subject to many painful procedures. Pharmacological and non-pharmacological approaches alone are not enough, and it is necessary to consider other contributing elements such as the environment, interprofessional collaboration and parental involvement. The aim of this feasibility study was to explore interprofessionality and the role of parents in improving the management of painful procedures in newborns and pain management strategies. Materials and Methods: a pre-post feasibility study using a mixed method approach was conducted. Questionnaires, interviews and focus groups were used to describe the parents' views on their child's pain management and involvement in care as well as to explore the level of interprofessionality and feasibility. Results: Collaboration between physicians and nurses improved following the implementation of a complex interprofessional intervention involving professionals, parents and newborns. In spite of improving professional collaboration in procedural pain management, parents were attributed a passive role or only marginally involved in in the infant's pain management. However, parents stated-as elicited by the questionnaires and interviews-that they wished to receive more information and be included in painful procedures executed on their infant. Discussion: Management of painful procedures in neonates needs to be changed. Interprofessional collaboration contributes to improved procedural pain management in neonates. It is essential to include parents as active members in the interprofessional healthcare team.

The Meta Salud Diabetes Implementation Study: Qualitative Methods to Assess Integration of a Health Promotion Intervention Into Primary Care to Reduce CVD Risk Among an Underserved Population With Diabetes in Sonora, Mexico

Background: Within health promotion research, there is a need to assess strategies for integration and scale up in primary care settings. Hybrid interventions that combine clinical effectiveness trials with implementation studies can elicit important contextual information on facilitators and barriers to integration within a health care system. This article describes lessons learned in developing and implementing a qualitative study of a cluster-randomized controlled trial (RCT) to reduce cardiovascular disease (CVD) among people with diabetes in Sonora, Mexico, 2015–2019.

Methods:The research team worked cooperatively with health center personnel from 12 Centers that implemented the intervention. The study used observations, stakeholder meetings, case studies, staff interviews and decision maker interviews to explore issues such as staff capacity, authority, workflow, space, and conflicting priorities, as well as patients' response to the program within the clinical context and their immediate social environments. Applying a multi-layered contextual framework, two members of the research team coded an initial sample of the data to establish inclusion criteria for each contextual factor. The full team finalized definitions and identified sub nodes for the final codebook.

Results: Characteristics of management, staffing, and the local environment were identified as essential to integration and eventual adoption and scale up across the health system. Issues included absence of standardized training and capacity building in chronic disease and health promotion, inadequate medical supplies, a need for program monitoring and feedback, and lack of interdisciplinary support for center staff. Lack of institutional support stemming from a curative vs. preventive approach to care was a barrier for health promotion efforts. Evolving analysis, interpretation, and discussion resulted in modifications of flexible aspects of the intervention to realities of the health center environment.

Conclusion: This study illustrates that a robust and comprehensive qualitative study of contextual factors across a social ecological spectrum is critical to elucidating factors that will promote future adoption and scale up of health promotion programs in primary care. Application of conceptual frameworks and health behavior theory facilitates identification of facilitators and barriers across contexts.

Trial registration:www.ClinicalTrials.gov, identifier: NCT02804698 Registered on June 17, 2016.

Reducing recurrent hospital admissions in patients with decompensated cirrhosis

Recurrent admissions to hospital are a major issue for people living with decompensated cirrhosis, particularly those who develop chronic hepatic encephalopathy, a condition that leads to significantly impaired quality of life for patients and their family caregivers. Such patients have high health-care use costs but recent data have shown how the appropriate use of effective medical therapy can significantly reduce hospital admissions, length of stay and unplanned readmissions. Redesigning clinical services to optimize access to specialist care and improving the education and support of patients and their carers can further help to reduce the burden of this disease.

Exploring individual and contextual factors contributing to tobacco cessation intervention implementation

BACKGROUND

Previous research suggests that smoking cessation interventions are poorly implemented. This study reports the development and testing of a questionnaire including knowledge, attitude, behavioral, and organizational (KABO) factors affecting the implementation of smoking cessation practices in hospitals by health care providers and organizations.

METHODS

An initial pool of 44 items was developed to assess the individual knowledge, attitudes, and beliefs of health professionals towards smoking cessation practices according to the 5 A's intervention model, as well as organizational barriers and opportunities for its implementation. Items were measured in a scale from 0="Not at all/Never" to 10 = "Completely/Always". Data were collected from health workers (n = 702) in Catalonia. The validity of the instrument was measured by: (a) analyzing the items, (b) assessing the internal structure, (c) estimating the internal consistency, and (d) analyzing the relationship between this tool and the 5 A's intervention model.

RESULTS

Seven domains were extracted: individual skills, positive organizational support, attitudes and beliefs, individual commitment, organizational resources, beliefs about patient desire/readiness to quit, and organizational endorsement. These domains explained 69.7% of the variance, and allowed for the development of a refined 26-item version of the questionnaire. Both the seven domains and the total scale showed adequate internal consistency.

CONCLUSIONS

Psychometric testing indicates that the KABO questionnaire is a reliable and valid instrument for assessing the main barriers and facilitators to smoking cessation intervention implementation. Individual factors better explained the implementation of smoking cessation interventions in hospitals, and the seven identified domains can be used for further investigations into how the implementation of evidence-based practices impacts smoking cessation performance.

Family Presence During Resuscitation: Physicians' Perceptions of Risk, Benefit, and Self-Confidence

BACKGROUND

Families often desire proximity to loved ones during life-threatening resuscitations and perceive clear benefits to being present. However, critical care nurses and physicians perceive risks and benefits. Whereas research is accumulating on nurses' perceptions of family presence, physicians' perspectives have not been clearly explicated. Psychometrically sound measures of physicians' perceptions are needed to create new knowledge and enhance collaboration among critical care nurses and physicians during resuscitation events.

OBJECTIVE

This study tests 2 new instruments that measure physicians' perceived risks, benefits, and self-confidence related to family presence during resuscitation.

METHODS

By a correlational design, a convenience sample of physicians (N = 195) from diverse clinical specialties in 1 hospital in the United States completed the Physicians' Family Presence Risk-Benefit Scale and Physicians' Family Presence Self-confidence Scale.

RESULTS

Findings supported the internal consistency reliability and construct validity of both new scales. Mean scale scores indicated that physicians perceived more risk than benefit and were confident in managing resuscitations with families present, although more than two-thirds reported feeling anxious. Higher self-confidence was significantly related to more perceived benefit and less perceived risk (P = .001). Younger physicians, family practice physicians, and physicians who previously had invited family presence expressed more positive perceptions (P = .05-.001).

DISCUSSION

These 2 new scales offer a means to assess key perceptions of physicians related to family presence. Further testing in diverse physician populations may further validate the scales and yield knowledge that can strengthen collaboration among critical care nurses and physicians and improve patient and family outcomes.

Exploration of the experiences, practices and needs of health promotion professionals when evaluating their interventions and programmes

INTRODUCTION

The aim of this study was to describe the practices of health promotion professionals when evaluating interventions and their transferability and to identify these professionals' needs in relation to a tool that will guide them during monitoring and evaluation.

METHOD

A survey was carried out among health promotion actors, which focussed on the interventions they had carried out.

RESULTS

Of the 1017 organisations (covering the whole of France) approached, 246 responded to the survey. More than 60% of the respondents had faced difficulties during the construction of the process evaluation, and more than 50% had faced difficulties during its implementation. These difficulties related to data collection, the conception or choice of indicators, criteria and relevant evaluation tools, and lack of time and personnel. Eighty per cent reported that they had carried out the same action in different places and had been faced with two main obstacles, namely budget and environment. Recognition, positive evaluation, existing collaborations and willingness to work in partnership plus the capacity to adapt to local contexts were identified as factors fostering transferability.

DISCUSSION

Despite the many recommendations available, constructing and carrying out evaluations is not systematic. Actors are confronted with many difficulties, which could be overcome with an IT tool that incorporates the actors' suggestions during its development.

Associations among unit leadership and unit climates for implementation in acute care: a cross-sectional study

Background

Nurse managers have a pivotal role in fostering unit climates supportive of implementing evidence-based practices (EBPs) in care delivery. EBP leadership behaviors and competencies of nurse managers and their impact on practice climates are widely overlooked in implementation science. The purpose of this study was to examine the contributions of nurse manager EBP leadership behaviors and nurse manager EBP competencies in explaining unit climates for EBP implementation in adult medical-surgical units.

Methods

A multi-site, multi-unit cross-sectional research design was used to recruit the sample of 24 nurse managers and 553 randomly selected staff nurses from 24 adult medical-surgical units from 7 acute care hospitals in the Northeast and Midwestern USA. Staff nurse perceptions of nurse manager EBP leadership behaviors and unit climates for EBP implementation were measured using the Implementation Leadership Scale and Implementation Climate Scale, respectively. EBP competencies of nurse managers were measured using the Nurse Manager EBP Competency Scale. Participants were emailed a link to an electronic questionnaire and asked to respond within 1 month. The contributions of nurse manager EBP leadership behaviors and competencies in explaining unit climates for EBP implementation were estimated using mixed-effects models controlling for nurse education and years of experience on current unit and accounting for the variability across hospitals and units. Significance level was set at α < .05.

Results

Two hundred sixty-four staff nurses and 22 nurse managers were included in the final sample, representing 22 units in 7 hospitals. Nurse manager EBP leadership behaviors (p < .001) and EBP competency (p = .008) explained 52.4% of marginal variance in unit climate for EBP implementation. Leadership behaviors uniquely explained 45.2% variance. The variance accounted for by the random intercepts for hospitals and units (p < .001) and years of nursing experience in current unit (p < .05) were significant but level of nursing education was not.

Conclusion

Nurse managers are significantly related to unit climates for EBP implementation primarily through their leadership behaviors. Future implementation studies should consider the leadership of nurse managers in creating climates supportive of EBP implementation.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0753-6) contains supplementary material, which is available to authorized users.

Effectiveness and cost-effectiveness of implementing HIV testing in primary care in East London: protocol for an interrupted time series analysis

INTRODUCTION

HIV remains underdiagnosed. Guidelines recommend routine HIV testing in primary care, but evidence on implementing testing is lacking. In a previous study, the Rapid HIV Assessment 2 (RHIVA2) cluster randomised controlled trial, we showed that providing training and rapid point-of-care HIV testing at general practice registration (RHIVA2 intervention) in Hackney led to cost-effective, increased and earlier diagnosis of HIV. However, interventions effective in a trial context may be less so when implemented in routine practice. We describe the protocol for an MRC phase IV implementation programme, evaluating the impact of rolling out the RHIVA2 intervention in a post-trial setting. We will use a longitudinal study to examine if the post-trial implementation in Hackney practices is effective and cost-effective, and a cross-sectional study to compare Hackney with two adjacent boroughs providing usual primary care (Newham) and an enhanced service promoting HIV testing in primary care (Tower Hamlets).

METHODS AND ANALYSIS

Service evaluation using interrupted time series and cost-effectiveness analyses. We will include all general practices in three contiguous high HIV prevalence East London boroughs. All adults aged 16 and above registered with the practices will be included. The interventions to be examined are: a post-trial RHIVA2 implementation programme (including practice-based education and training, external quality assurance, incentive payments for rapid HIV testing and incorporation of rapid HIV testing in the sexual health Local Enhanced Service) in Hackney; the general practice sexual health Network Improved Service in Tower Hamlets and usual care in Newham. Coprimary outcomes are rates of HIV testing and new HIV diagnoses.

ETHICS AND DISSEMINATION

The chair of the Camden and Islington NHS Research Ethics Committee, London, has endorsed this programme as an evaluation of routine care. Study results will be published in peer-reviewed journals and reported to commissioners.

Assessing Capacity of Faith-Based Organizations for Health Promotion Activities

BACKGROUND

Faith-based organizations (FBOs) are important venues for health promotion, particularly in medically underserved communities. These organizations vary considerably in their structural capacities, which may be linked to variability in implementation success for health promotion initiatives. Lacking an existing validated assessment of organizational capacity specific to FBOs, an initial prototype assessment was developed.

METHOD

The Faith-Based Organization Capacity Inventory (FBO-CI) assesses three structural areas of capacity: Staffing and Space, Health Promotion Experience, and External Collaboration. The multidisciplinary team, including FBO leaders, codeveloped the initial instrument. The initial reliability from a convenience sample of 34 African American churches including descriptions of FBOs representing three capacity levels is reported.

RESULTS

The FBO-CI demonstrated feasibility of administration using an in-person interview format, and the three subscales had acceptable internal reliability (α ~ .70). Most churches had an established health ministry (n = 23) and had conducted activities across an average of seven health areas in the previous 2 years.

CONCLUSIONS

This initial FBO-CI prototype is promising, and future work should consider validation with a larger sample of churches and domain expansion based on the conceptual model. The FBO-CI has a number of potential uses for researchers, FBO leaders, and practitioners working with FBOs in health promotion initiatives.

Developing implementation science to improve the translation of research to address low back pain: A critical review

The evidence base regarding treatment for back pain does not align with clinical practice. Currently there is relatively little evidence to guide health decision-makers on how to improve the use, uptake or adoption of evidence-based recommended practice for low back pain. Improving the design, conduct and reporting of strategies to improve the implementation of back pain care will help address this important evidence-practice gap. In this paper, we.

Operational Failures Detected by Frontline Acute Care Nurses

Frontline nurses encounter operational failures (OFs), or breakdowns in system processes, that hinder care, erode quality, and threaten patient safety. Previous research has relied on external observers to identify OFs; nurses have been passive participants in the identification of system failures that impede their ability to deliver safe and effective care. To better understand frontline nurses' direct experiences with OFs in hospitals, we conducted a multi-site study within a national research network to describe the rate and categories of OFs detected by nurses as they provided direct patient care. Data were collected by 774 nurses working in 67 adult and pediatric medical-surgical units in 23 hospitals. Nurses systematically recorded data about OFs encountered during 10 work shifts over a 20-day period. In total, nurses reported 27,298 OFs over 4,497 shifts, a rate of 6.07 OFs per shift. The highest rate of failures occurred in the category of Equipment/Supplies, and the lowest rate occurred in the category of Physical Unit/Layout. No differences in OF rate were detected based on hospital size, teaching status, or unit type. Given the scale of this study, we conclude that OFs are frequent and varied across system processes, and that organizations may readily obtain crucial information about OFs from frontline nurses. Nurses' detection of OFs could provide organizations with rich, real-time information about system operations to improve organizational reliability. © 2017 Wiley Periodicals, Inc.

Pain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial

OBJECTIVE

To enhance pain practices in nursing homes (NHs) using pain assessment and management algorithms and intense diffusion strategies.

DESIGN

A cluster, randomized controlled trial. The intervention consisted of intensive training and support for the use of recommended pain assessment and management practices using algorithms (ALGs). Control facilities received pain education (EDU) only.

SETTING

Twenty-seven NHs in the greater Puget Sound area participated. Facilities were diverse in terms of size, quality, and ownership.

PARTICIPANTS

Data were collected from 485 NH residents; 259 for the intervention and 226 for the control group.

MEASUREMENTS

Resident outcomes were nursing assistant (proxy) report and self-reported resident pain intensity. Process outcomes were adherence to recommended pain practices. Outcomes were measured at baseline, completion of the intervention (ALG) or training (EDU), and again 6 months later.

RESULTS

Among 8 comparisons of outcome measures between ALG and EDU (changes in 4 primary pain measures compared at 2 postintervention time points) there was only 1 statistically significant but small treatment difference in proxy- or self-reported pain intensity. Resident-reported worst pain decreased by an average of 0.8 points from baseline to 6 months among the EDU group and increased by 0.2 points among the ALG (P = .005), a clinically nonsignificant difference. There were no statistically significant differences in adherence to clinical guideline practice recommendations between ALG and EDU following the intervention.

CONCLUSIONS

Future research needs to identify and test effective implementation methods for changing complex clinical practices in NHs, including those to reduce pain.

Study protocol for "Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET)": a pragmatic trial comparing implementation strategies

BACKGROUND

Little research has directly compared the effectiveness of implementation strategies in any setting, and we know of no prior trials directly comparing how effectively different combinations of strategies support implementation in community health centers. This paper outlines the protocol of the Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET), a trial designed to compare the effectiveness of several common strategies for supporting implementation of an intervention and explore contextual factors that impact the strategies' effectiveness in the community health center setting.

METHODS/DESIGN

This cluster-randomized trial compares how three increasingly hands-on implementation strategies support adoption of an evidence-based diabetes quality improvement intervention in 29 community health centers, managed by 12 healthcare organizations. The strategies are as follows: (arm 1) a toolkit, presented in paper and electronic form, which includes a training webinar; (arm 2) toolkit plus in-person training with a focus on practice change and change management strategies; and (arm 3) toolkit, in-person training, plus practice facilitation with on-site visits. We use a mixed methods approach to data collection and analysis: (i) baseline surveys on study clinic characteristics, to explore how these characteristics impact the clinics' ability to implement the tools and the effectiveness of each implementation strategy; (ii) quantitative data on change in rates of guideline-concordant prescribing; and (iii) qualitative data on the "how" and "why" underlying the quantitative results. The outcomes of interest are clinic-level results, categorized using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, within an interrupted time-series design with segmented regression models. This pragmatic trial will compare how well each implementation strategy works in "real-world" practices.

DISCUSSION

Having a better understanding of how different strategies support implementation efforts could positively impact the field of implementation science, by comparing practical, generalizable methods for implementing clinical innovations in community health centers. Bridging this gap in the literature is a critical step towards the national long-term goal of effectively disseminating and implementing effective interventions into community health centers.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02325531.

Developing standards for reporting implementation studies of complex interventions (StaRI): a systematic review and e-Delphi

BACKGROUND

Dissemination and implementation of health care interventions are currently hampered by the variable quality of reporting of implementation research. Reporting of other study types has been improved by the introduction of reporting standards (e.g. CONSORT). We are therefore developing guidelines for reporting implementation studies (StaRI).

METHODS

Using established methodology for developing health research reporting guidelines, we systematically reviewed the literature to generate items for a checklist of reporting standards. We then recruited an international, multidisciplinary panel for an e-Delphi consensus-building exercise which comprised an initial open round to revise/suggest a list of potential items for scoring in the subsequent two scoring rounds (scale 1 to 9). Consensus was defined a priori as 80% agreement with the priority scores of 7, 8, or 9.

RESULTS

We identified eight papers from the literature review from which we derived 36 potential items. We recruited 23 experts to the e-Delphi panel. Open round comments resulted in revisions, and 47 items went forward to the scoring rounds. Thirty-five items achieved consensus: 19 achieved 100% agreement. Prioritised items addressed the need to: provide an evidence-based justification for implementation; describe the setting, professional/service requirements, eligible population and intervention in detail; measure process and clinical outcomes at population level (using routine data); report impact on health care resources; describe local adaptations to the implementation strategy and describe barriers/facilitators. Over-arching themes from the free-text comments included balancing the need for detailed descriptions of interventions with publishing constraints, addressing the dual aims of reporting on the process of implementation and effectiveness of the intervention and monitoring fidelity to an intervention whilst encouraging adaptation to suit diverse local contexts.

CONCLUSIONS

We have identified priority items for reporting implementation studies and key issues for further discussion. An international, multidisciplinary workshop, where participants will debate the issues raised, clarify specific items and develop StaRI standards that fit within the suite of EQUATOR reporting guidelines, is planned.

REGISTRATION

The protocol is registered with Equator: http://www.equator-network.org/library/reporting-guidelines-under-development/#17 .

Implementation of a heart failure quality initiative in a skilled nursing facility: lessons learned

Skilled nursing facilities (SNFs) are organizations that represent complex adaptive systems, offering barriers to the implementation of quality improvement (QI) initiatives. The current article describes the authors' efforts to use the approach of reflective adaptive process to implement a new model of care (i.e., the Skilled Heart Unit Program) for effective heart failure (HF) care in one SNF. A team of stakeholders from the local hospital system and a local SNF was convened to design and implement this new model. Evaluation of the implementation processes confirmed the value of the implementation approach, which centered on team-based approaches, staff engagement, and flexibility of processes to respect the SNF's needs and culture. Interviews with facility staff and the administrator revealed their perceptions that the strategy resulted in better HF care, enhanced teamwork between staff and clinicians, and improved staff job satisfaction. This work provides a unique blueprint of strategic QI implementation for patients with HF in the SNF setting.

Phase IV implementation studies. The forgotten finale to the complex intervention methodology framework

The complex intervention methodology framework defines the iterative process for developing and evaluating complex interventions in healthcare, but advice on implementation research was not included until the 2008 update. Our recent systematic review of implementation studies identified significant problems with reporting standards, including inconsistent terminology and crucial information that was missing or unclear. Introduction of reporting checklists has standardized the reporting of randomized controlled trials and other types of studies, and there is a need for similar guidance for reporting implementation studies. Key standards might include an explicit evidence base from a randomized controlled trial or guideline recommendation; recruitment to the clinical service, not the research; at least some outcomes at the population level using routinely collected data; and a description of the setting and the process of implementing the service. The complex intervention framework currently illustrates a cycle of development and evaluation, which includes implementation as a final step. We propose that the research underpinning implementation should be visualized as a second interrelated cycle. Just as the "phase III cycle" includes the iterative steps of development and piloting, a similar process may be needed to translate the intervention into a practical service that can be tested in a phase IV implementation study.

Developing a clinical care pathway for obese pregnant women: A quality improvement project

PROBLEM

Obesity in pregnancy is associated with an increased incidence of maternal and foetal morbidity and mortality, from conditions like preeclampsia, gestational diabetes, preterm birth and stillbirth. Between 20% and 25% of pregnant women in Australia are presenting to their first antenatal appointment with a body mass index (BMI) ≥ 30 kg/m(2), defined as obesity in pregnancy. These figures are concerning for midwifery and obstetric staff directly involved in the clinical care of these women and their families. In the absence of national or state clinical practice guidelines for managing the risks for obese pregnant women, a local quality improvement project was conducted.

AIM

To plan, implement, and evaluate the impact of an alternative clinical care pathway for pregnant women with a BMI ≥ 35 kg/m(2) at their first antenatal visit.

PROJECT SETTING

The project was undertaken in the antenatal clinic of a rural referral hospital in NSW, Australia.

SUBJECTS

Eighty-two women with a BMI ≥ 35 kg/m(2) were eligible for the alternative care pathway, offered between January and December 2010.

INTERVENTION

The alternative care pathway included the following options, in addition to usual care: written information on obesity in pregnancy, referral to a dietitian, early plus repeat screening for gestational diabetes, liver and renal function pathology tests, serial self-weighing, serial foetal growth ultrasounds, and a pre-labour anaesthetic consultation.

FINDINGS

Despite being educated on the risk associated with obesity in pregnancy, women did not take up the offers of dietetic support or self-weighing at each antenatal visit. Ultrasounds were well received and most women underwent gestational diabetes screening.

Introduction: the Interdisciplinary Nursing Quality Research Initiative

BACKGROUND

The Robert Wood Johnson Foundation launched the Interdisciplinary Nursing Quality Research Initiative (INQRI) program in 2005 to generate, disseminate, and translate research to understand how nurses contribute to and can improve patient care quality. This special edition of Medical Care provides an overview of the program's strategy, goals, and impact, highlighting cross-cutting issues addressed by the initiative.

METHODS

INQRI's leadership and select grantees discuss the implications of a collection of studies on the following: advances in the science of nursing's contribution to quality, measurement of quality, interdisciplinary collaboration, implementation methodology, dissemination and translation of findings, and the business case for nursing.

RESULTS

A comprehensive review of the scholarly literature published in 2004 and 2009 found that the evidence linking nursing to quality of care has grown. The second paper discusses INQRI's work on measurement of quality of care, revealing the need for additional comprehensive measures. The third paper examines INQRI's focus on interdisciplinary collaboration, finding that it can enhance methodological approaches and result in substantive changes in health delivery systems. The fourth paper presents methodological challenges faced in health care implementation, emphasizing the need for standardized terms and research designs. The fifth paper addresses INQRI's commitment to translating research into practice, illustrating dissemination strategies and lessons learned. The final paper discusses how the INQRI program has contributed to the current evidence regarding the business case for nursing.

DISCUSSION

This supplement describes the accomplishments of the INQRI program, discusses current issues in research design and implementation, and places INQRI research within the larger context regarding advances in nursing science.