A conceptual model to guide research on the activities and effects of innovation champions

Key informants' perceptions of telehealth palliative care for people living with dementia in nursing homes

BACKGROUND

Studies have shown that palliative care delivered to people living with dementia (PLWD) in nursing homes (NHs) improves care quality and reduces potentially burdensome treatments. However, access to palliative care services in NHs is uncommon. Telehealth may extend the reach of specialty palliative care consultation, yet strategies for feasible and acceptable NH implementation remain unknown. During implementation of an embedded pragmatic pilot clinical trial for PLWD, we aimed to describe key informants' perceptions of a NH telehealth palliative care intervention.

METHODS

Guided by the Practical Implementation Sustainability Model (PRISM), we engaged key informants in 30-60-minute focus groups and individual semi-structured interviews to understand barriers and facilitators to implementation of a NH telehealth palliative care intervention in one NH. Interview prompts addressed contextual factors that influenced outcomes. Interviews were conducted and recorded via videoconference, transcribed, and analyzed using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

RESULTS

Participants (n = 14) included NH administrators and other leaders, palliative care providers, telehealth representatives, dementia advocates, a care partner, and a PLWD. Identified barriers to implementation included stigma surrounding dementia, palliative care, and NHs; multiple logistical pieces required to implement the intervention; inflexibility of palliative care providers to meet NH needs; and inability to assess residents in person. Facilitators included convenient, user-friendly and readily available telehealth equipment, and NH staff presence during visits. Outcomes most relevant to the key informants were increased goals of care conversations, improved symptom management and quality of life, and decreased health care utilization. Suggested adaptations included increased family engagement in the logistics of the intervention and strong NH advocacy.

CONCLUSIONS

In this study, key informants provided feedback that barriers to implementing NH telehealth palliative care far outweighed the facilitators for uptake. Future work will focus on employing NH staff in user centered design to overcome barriers such as optimal timing for consults and/or scheduled consult days to fit NH workflow, assessing organizational readiness for implementing change, and identifying dementia-specific and palliative care education needs.

Support for a Weight-Inclusive Curriculum? Exploring Partner Perspectives and Influences on Nutrition Education in Vermont High Schools

BACKGROUND

The weight-normative approach to nutrition education dominates health education programming across the United States, despite evidence that this paradigm contributes to negative outcomes including weight cycling, bias and stigma, the development of disordered eating behaviors, and weight-based bullying.

METHODS

This study investigates perspectives of 10 potential partners with interest in and potential to influence nutrition education. Through qualitative interviews and document analysis, researchers explored support for a weight-inclusive curriculum and factors that influence high school nutrition curricular content and implementation.

RESULTS

Findings indicate that partners hold both weight-inclusive and weight-normative values, guidance around nutrition curricular content is lacking, and state-level policy is crucial to the valuing and implementation of consistent curricula.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

Lack of guidance or mandated curricular content contributes to inequities across the state. Weight-inclusive curricular materials are needed. Administration must take an active role in providing access to professional development and state policy support for curricular implementation is essential.

CONCLUSIONS

Weight-inclusive curriculum could serve to improve health outcomes for adolescents. However, successful implementation of, or changes to, health and nutrition curricula will require support and engagement from partners at all ecological levels.

Identifying and supporting vaccine champions in pediatric primary care: a qualitative interview study

Implementation science research identifies clinical champions as instrumental in aligning healthcare professionals' (HCPs) behavior with practice guidelines for delivering health services, including vaccinations. However, we know relatively little about identifying or supporting champions. To characterize who vaccine champions are, what they do, and how to support their work in pediatric primary care. In 2022, we interviewed a purposive sample of peer-nominated or self-identified vaccine champions (n=20) and HCPs who worked with vaccine champions (n=4). We thematically analyzed qualitative data. Vaccine champions' defining characteristics were firsthand primary care experience, whether as providers or nursing staff, and a strong belief in vaccinations as uniquely effective tools for primary prevention. Participants noted these beliefs were "part of the DNA" of specialties like pediatrics and infectious disease, where they perceived champions as especially common. Being "insatiable in their quest for knowledge," champions primarily conceptualized their role as understanding and sharing complex information and performance metric data related to vaccine administration. Champions' role in leading other implementation strategies, such as communication training, was more peripheral. Champions reported that dedicated time and staff support helped them "go above and beyond" to improve vaccination rates. Our findings suggest that vaccine champions can be found among providers and nursing staff with deep clinical experience and commitment to primary prevention through vaccination, including through providing vaccine education to colleagues. Healthcare systems can allocate resources to support champions as educators, while exploring opportunities to extend their role in other implementation strategies to improve vaccination rates.

Champions to enhance implementation of clinical and community-based interventions in cancer: a scoping review

BACKGROUND

Champions are integral across research in cancer, yet studies exploring their roles are limited and have produced mixed results. The current review examines and synthesizes descriptions of how champions emerged and the types of activities they most often performed. By examining evidence from across the translational research continuum, this scoping review aims to characterize the role of champions and strategies that facilitate their involvement in the implementation of cancer care interventions in both clinical and community-based settings.

METHODS

This scoping review was designed and implemented in compliance with PRISMA-ScR. The review focused on peer-reviewed articles in English-language journals. We searched five databases: PubMed (including MEDLINE), Scopus (including EMBASE), CINAHL, PsycINFO, and the Cochrane Library. Articles published from 1971 to 2022 were included. Two members of the team reviewed in duplicate each article and then a single member of the team extracted the data in Covidence, with a second member comparing the extraction to the original article. Qualitative and quantitative data were extracted and then synthesized. These data were used to summarize core champion activities and implementation strategies and to characterize barriers and facilitators to using champions in research.

RESULTS

A total of 74 articles were included in the review. The qualitative synthesis highlighted facilitators and barriers to the effective use of champions. Facilitators included consideration of an individual's characteristics when identifying champions, time spent planning for the specific responsibilities of champions, working within a supportive environment, and identifying champions embedded in the target setting. Major barriers included constrained time, low self-efficacy among champions, inadequate training, high turnover rates of champions, and a lack of buy-in from organizational leadership toward the intervention. Champions also were mostly assigned their roles, had varied core activities, and used complementary strategies to empower their target populations. Champions' most frequent core activities include facilitation, outreach/promotion, and recruitment of participants into studies.

CONCLUSIONS

Champions were used in research of many cancer types and often serve similar roles regardless of where they are located within the translational research process. Despite their critical role, evidence is lacking on the impact of champions specifically on outcomes of many of the research studies that include them. Future research is needed to understand the nuances of champion-driven approaches across diverse cancer care settings.

Implementing an early-life nutrition intervention through primary healthcare: staff perspectives

BACKGROUND

Nutrition interventions targeting early childhood can be cost-effective and may provide lifelong, intergenerational benefits. From October 2022 to April 2023 the Nutrition Now (NN) e-learning resource was implemented within Early Childhood Education and Care centres and the Maternal and Child Healthcare Centre (MCHC) in a southern Norwegian municipality. As part of the NN project, the present study aims to explore the MCHC staff's experiences with implementing the NN resource, to gain insights into measures important to scale up digital early-life nutrition interventions.

METHODS

Three group interviews were conducted among public health nurses and midwives alongside one individual interview with the department leader of a MCHC in May 2023. An inductive thematic analysis, as described by Braun and Clarke, was conducted to generate the key themes and subthemes regarding the implementation process of NN within the MCHC.

RESULTS

Three main themes were generated: [1] Important resource but not always utilized; [2] Parents are interested but had issues with access; and [3] Staff and stakeholder buy-in and commitment needed from the start. Overall, the staff viewed the NN resource as a potential tool for promoting diet-related topics and believed it could support the guidance they were already providing parents. However, few staff members fully familiarized themselves with the resource. While staff perceived parents as positive when informed about NN, they believed issues such as access challenges, competing platforms, and time constraints reduced parental engagement. Lastly, staff suggested improvements for NN's implementation, including enhanced training, better planning, assigning champions, and lowering the threshold for access.

CONCLUSION

The findings of this study suggest that the real-world implementation of digital evidence-based health behaviour interventions is feasible but would be enhanced by employing strategies focusing on engagement and utilization.

TRIAL REGISTRATION

The main study is registered in the ISRCTN registry with ID ISRCTN10694967, https://doi.org/10.1186/ISRCTN10694967 . (Registration date: 19-06-2022).

Exploring gaps, opportunities, barriers and enablers in malnutrition policy through key informant interviews: a qualitative inquiry from the CANDReaM initiative

ABSTRACT

Objectives

Disease-related malnutrition (DRM) presents in up to half of adults and one-third of children admitted to Canadian hospitals and significantly impacts health outcomes. Strategies to screen, diagnose and treat DRM exist but policy to facilitate implementation and sustainability are lacking. The purpose of this study was to explore gaps, opportunities, barriers and enablers for DRM policy in Canada.

Methods

A qualitative study was conducted with multi-national key informants in DRM and/or health policy. Purposive sampling identified participants for a semi-structured interview. The health policy triangle framework informs policy outcomes by considering actors, content, context and processes, and was used to guide this work. Inductive thematic analysis was completed, followed by deductive analysis based on the framework.

Results

DRM policy actors were seen as champions in healthcare, senior leaders in healthcare administration and individuals with lived experience. Policy content focused on screening, diagnosis and treatment of DRM. Key areas related to policy context included system specifics related to setting, cost and capacity, and social determinants of health. DRM policy processes were viewed as cross-sectoral and multi-level governance, mandating and other reinforcement strategies, windows of opportunity, and evaluation and research.

Conclusions

DRM care has advanced substantially, yet policy-level changes are sparse, and gaps exist. DRM policy is facilitated by similar content around the globe and needs to be tailored to address setting-specific needs. Actors, content, context and processes inform policy and can be a dominant lever to accelerate nutrition care best practices.

Changing hearts and minds: theorizing how, when, and under what conditions three social influence implementation strategies work

Background

Opinion leadership, educational outreach visiting, and innovation championing are commonly used strategies to address barriers to implementing innovations and evidence-based practices in healthcare settings. Despite voluminous research, ambiguities persist in how these strategies work and under what conditions they work well, work poorly, or work at all. The current paper develops middle-range theories to address this gap.

Methods

Conceptual articles, systematic reviews, and empirical studies informed the development of causal pathway diagrams (CPDs). CPDs are visualization tools for depicting and theorizing about the causal process through which strategies operate, including the mechanisms they activate, the barriers they address, and the proximal and distal outcomes they produce. CPDs also clarify the contextual conditions (i.e., preconditions and moderators) that influence whether, and to what extent, the strategy's causal process unfolds successfully. Expert panels of implementation scientists and health professionals rated the plausibility of these preliminary CPDs and offered comments and suggestions on them.

Findings

Theoretically, opinion leadership addresses potential adopters' uncertainty about likely consequences of innovation use (determinant) by promoting positive attitude formation about the innovation (mechanism), which results in an adoption decision (proximal outcome), which leads to innovation use (intermediate outcome). As this causal process repeats, penetration, or spread of innovation use, occurs (distal outcome). Educational outreach visiting addresses knowledge barriers, attitudinal barriers, and behavioral barriers (determinants) by promoting critical thinking and reflection about evidence and practice (mechanism), which results in behavioral intention (proximal outcome), behavior change (intermediate outcome), and fidelity, or guideline adherence (distal outcome). Innovation championing addresses organizational inertia, indifference, and resistance (determinants) by promoting buy-in to the vision, fostering a positive implementation climate, and increasing collective efficacy (mechanisms), which leads to participation in implementation activities (proximal outcome), initial use of the innovation with increasing skill (intermediate outcome) and, ultimately, greater penetration and fidelity (distal outcomes). Experts found the preliminary CPDs plausible or highly plausible and suggested additional mechanisms, moderators, and preconditions, which were used to amend the initial CPD.

Discussion

The middle-range theories depicted in the CPDs furnish testable propositions for implementation research and offer guidance for selecting, designing, and evaluating these social influence implementation strategies in both research studies and practice settings.

Barriers and facilitators to evidence-based perioperative hypothermia management for orthopaedic patients: A systematic review

AIM

To assess barriers and facilitators to the implementation of guidelines for the prevention of inadvertent perioperative hypothermia in orthopaedic patients.

DESIGN

Systematic review.

DATA SOURCES

Nine databases: PubMed, Embase, CINAHL, Cochrane CENTRAL, PsycINFO, ProQuest Dissertations and Theses, Scopus, Web of Science and Trip Clinical Evidence Database.

METHODS

Primary studies published in English between January 2008 to July 2022 were screened. Study selection, quality assessment, and data extraction were completed independently by researchers. Data were extracted using the Consolidated Framework for Implementation Research and mapped to the Expert Recommendations for Implementing Change strategies.

RESULTS

Eighty-seven studies were included in the review. The most frequently reported barriers and facilitators related to evidence strength, relative advantage, and cost of implementing perioperative hypothermia prevention guidelines. The top four ERIC strategies were: Identify and prepare champions; Conduct educational meetings; Assess for readiness and identify barriers and facilitators; and Inform local opinion leaders.

CONCLUSION

This review provides synthesized evidence regarding barriers and facilitators to perioperative hypothermia guidelines for patients undergoing orthopaedic surgery.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Our work provides theory guided strategies to promote implementation of perioperative hypothermia prevention to assist nurses caring for patients undergoing orthopaedic surgery.

IMPACT

Findings provide professionals caring for patients undergoing orthopaedic surgery with theory-informed strategies to improve perioperative hypothermia prevention. Reducing perioperative hypothermia will improve outcomes for patients undergoing orthopaedic surgery.

REPORTING METHOD

The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020.

NO PATIENT OR PUBLIC CONSULTATION

Due to the study design, no patient or public consultation took place.

Establishing and sustaining high-quality services for people with young onset dementia: the perspective of senior service providers and commissioners

OBJECTIVES

We aimed to understand the facilitators to developing and sustaining high-quality services for people with young onset dementia (YOD) and their families/supporters.

DESIGN

This qualitative study used semi-structured interviews with commissioners and service managers, analyzed using inductive thematic analysis.

SETTING

A purposive sample of providers was selected from diverse areas and contrasting YOD services.

PARTICIPANTS

Eighteen senior staff from YOD services and two dementia service commissioners took part.

MEASUREMENTS

For commissioners, key interview topics were experiences of commissioning YOD services, perceived facilitators or barriers, and how future guidance should be structured for ease of use. For service providers, key topics explored experiences of delivering YOD services; what was achievable or challenging; how the service was funded; how it linked with broader provision for YOD in the area; and how guidance should be structured.

RESULTS

Recorded interviews lasted 30-40 minutes. Seven key facilitators to the development and sustaining of YOD services were identified: having knowledgeable, committed local champions; involvement of people living with YOD and family supporters; initial delivery within existing resources; partnership working within and between sectors; having a reflective, supportive organizational culture; gathering evidence of impact; and having wider support and guidance.

CONCLUSIONS

Improvements in provision for those with YOD and their families need to be built on understanding of service-level and interpersonal influences as well as on understanding of YOD itself. Our findings highlight a set of facilitators which need to be in place to establish and sustain high-quality YOD services that fit the local context.

Identifying effective vaccine champions: Findings from a national survey of primary care professionals

BACKGROUND

Vaccine champions are common in primary care, but little is known about which champions are effective.

METHODS

In 2022, we surveyed 2,144 US primary care professionals (PCPs) who reported working with vaccine champions. Respondents rated the champion with whom they worked most closely on their effectiveness at improving vaccination rates.

RESULTS

About half (49 %) of PCPs perceived their closest champion as highly effective. PCPs perceived advanced practice providers and nursing staff as highly effective somewhat more often than physicians (52 % and 58 % vs 43 %, p <.001). Other correlates of perceived effectiveness included being a formally appointed versus informal champion, working extremely versus less closely with PCPs, and using a high (4-5) versus low (0-1) number of implementation strategies to improve vaccination rates (all p <.001).

CONCLUSIONS

Results suggest vaccine champions may benefit from having formal roles and opportunities to work closely with colleagues to improve vaccination rates using multiple strategies.

Assessing Barriers to Utilization of Premedication for Neonatal Intubation Based on the Theoretical Domains Framework

OBJECTIVE

This study aimed to identify barriers and facilitators of premedication utilization for nonemergent neonatal intubations (NIs) in a level IV neonatal intensive care unit (NICU).

STUDY DESIGN

Between November 2018 and January 2019, multidisciplinary providers at a level IV NICU were invited to participate in an anonymous, electronic survey based on Theoretical Domains Framework to identify influences on utilization of evidence-based recommendations for NI premedication.

RESULTS

Of 186 surveys distributed, 84 (45%) providers responded. Most agreed with premedication use in the following domains: professional role/identity (86%), emotions (79%), skills (72%), optimism (71%), and memory, attention, and decision process (71%). Domains with less agreement include social influences (42%), knowledge (57%), intention (60%), belief about capabilities (63%), and behavior regulation (64%). Additional barriers include environmental context and resources, and beliefs about consequences.

CONCLUSION

Several factors influence premedication use for nonemergent NI and may serve as facilitators and/or barriers. Efforts to address barriers should incorporate a multidisciplinary approach to improve patient outcomes and decrease procedure-related pain.

KEY POINTS

· Premedication for NIs can optimize conditions and decrease rates of tracheal intubation adverse events but there is significant international and institutional variation for premedication use for NI.. · Guided by implementation science methods, the Theoretical Domains Framework was utilized to construct a novel assessment tool to determine potential barriers to and facilitators of the use of premedication for NI.. · Several factors influence premedication for nonemergent NI..

The role of champions in the implementation of technology in healthcare services: a systematic mixed studies review

BACKGROUND

Champions play a critical role in implementing technology within healthcare services. While prior studies have explored the presence and characteristics of champions, this review delves into the experiences of healthcare personnel holding champion roles, as well as the experiences of healthcare personnel interacting with them. By synthesizing existing knowledge, this review aims to inform decisions regarding the inclusion of champions as a strategy in technology implementation and guide healthcare personnel in these roles.

METHODS

A systematic mixed studies review, covering qualitative, quantitative, or mixed designs, was conducted from September 2022 to March 2023. The search spanned Medline, Embase, CINAHL, and Scopus, focusing on studies published from 2012 onwards. The review centered on health personnel serving as champions in technology implementation within healthcare services. Quality assessments utilized the Mixed Methods Appraisal Tool (MMAT).

RESULTS

From 1629 screened studies, 23 were included. The champion role was often examined within the broader context of technology implementation. Limited studies explicitly explored experiences related to the champion role from both champions' and health personnel's perspectives. Champions emerged as promoters of technology, supporting its adoption. Success factors included anchoring and selection processes, champions' expertise, and effective role performance.

DISCUSSION

The specific tasks and responsibilities assigned to champions differed across reviewed studies, highlighting that the role of champion is a broad one, dependent on the technology being implemented and the site implementing it. Findings indicated a correlation between champion experiences and organizational characteristics. The role's firm anchoring within the organization is crucial. Limited evidence suggests that volunteering, hiring newly graduated health personnel, and having multiple champions can facilitate technology implementation. Existing studies predominantly focused on client health records and hospitals, emphasizing the need for broader research across healthcare services.

CONCLUSIONS

With a clear mandate, dedicated time, and proper training, health personnel in champion roles can significantly contribute professional, technological, and personal competencies to facilitate technology adoption within healthcare services. The review finds that the concept of champions is a broad one and finds varied definitions of the champion role concept. This underscores the importance of describing organizational characteristics, and highlights areas for future research to enhance technology implementation strategies in different healthcare settings with support of a champion.

Who are vaccine champions and what implementation strategies do they use to improve adolescent HPV vaccination? Findings from a national survey of primary care professionals

BACKGROUND

Implementation science researchers often cite clinical champions as critical to overcoming organizational resistance and other barriers to the implementation of evidence-based health services, yet relatively little is known about who champions are or how they effect change. To inform future efforts to identify and engage champions to support HPV vaccination, we sought to describe the key characteristics and strategies of vaccine champions working in adolescent primary care.

METHODS

In 2022, we conducted a national survey with a web-based panel of 2527 primary care professionals (PCPs) with a role in adolescent HPV vaccination (57% response rate). Our sample consisted of pediatricians (26%), family medicine physicians (22%), advanced practice providers (24%), and nursing staff (28%). Our survey assessed PCPs' experience with vaccine champions, defined as health care professionals "known for helping their colleagues improve vaccination rates."

RESULTS

Overall, 85% of PCPs reported currently working with one or more vaccine champions. Among these 2144 PCPs, most identified the champion with whom they worked most closely as being a physician (40%) or nurse (40%). Almost all identified champions worked to improve vaccination rates for vaccines in general (45%) or HPV vaccine specifically (49%). PCPs commonly reported that champion implementation strategies included sharing information (79%), encouragement (62%), and vaccination data (59%) with colleagues, but less than half reported that champions led quality improvement projects (39%). Most PCPs perceived their closest champion as being moderately to extremely effective at improving vaccination rates (91%). PCPs who did versus did not work with champions more often recommended HPV vaccination at the earliest opportunity of ages 9-10 rather than later ages (44% vs. 33%, p < 0.001).

CONCLUSIONS

Findings of our national study suggest that vaccine champions are common in adolescent primary care, but only a minority lead quality improvement projects. Interventionists seeking to identify champions to improve HPV vaccination rates can expect to find them among both physicians and nurses, but should be prepared to offer support to more fully engage them in implementing interventions.

A taskforce for national improvement of innovation implementation in radiotherapy

BACKGROUND AND PURPOSE

Previous research among Dutch radiotherapy centres (RTCs) showed that 69% of innovations was simultaneously implemented in 7/19 centres, with a success rate of 51%. However, no structure to share lessons learned about the implementation process existed. Therefore, a national Taskforce Implementation (TTI) was raised to stimulate efficient implementation of innovations. The aim of the current study was to develop and pilot-evaluate a website for facilitating mutual learning on implementation issues.

MATERIAL AND METHODS

First, we made an inventory in all Dutch RTCs on their 10 most valuable innovations between 2019 and 2022. In-depth interviews, structured according to the Consolidated Framework for Implementation Research, were performed on the four most mentioned topics. A website was built, and pilot evaluated 1 year after the launch, using a qualitative survey amongst the TTI members.

RESULTS

In 13/18 centres, 19 interviews were conducted on 1) automation, 2) patient participation, 3) adaptive radiotherapy 4) surface guided radiotherapy and tracking. Most innovations (13/16) were implemented with a delay, with many comparable challenges: e.g. shortage of personnel (7/16) and prioritization of projects (9/16). The website allows users to upload and search for projects, including implementation experiences. After 1 year, 14 projects were uploaded. The qualitative evaluation was largely positive with room for improvement, i.e.75 % would recommend the website to others.

CONCLUSION

This study showed that RTCs experience comparable challenges when implementing innovations, thereby underlining the need for a platform to share implementation-lessons learned. The first concept of this platform was evaluated positively.

Exploring Shared Implementation Leadership of Point of Care Nursing Leadership Teams on Inpatient Hospital Units: Protocol for a Collective Case Study

BACKGROUND

Nursing leadership teams at the point of care (POC), consisting of both formal and informal leaders, are regularly called upon to support the implementation of evidence-based practices (EBPs) in hospital units. However, current conceptualizations of effective leadership for successful implementation typically focus on the behaviors of individual leaders in managerial roles. Little is known about how multiple nursing leaders in formal and informal roles share implementation leadership (IL), representing an important knowledge gap.

OBJECTIVE

This study aims to explore shared IL among formal and informal nursing leaders in inpatient hospital units. The central research question is as follows: How is IL shared among members of POC nursing leadership teams on inpatient hospital units? The subquestions are as follows: (1) What IL behaviors are enacted and shared by formal and informal leaders? (2) What social processes enable shared IL by formal and informal leaders? and (3) What factors influence shared IL in nursing leadership teams?

METHODS

We will use a collective case study approach to describe and generate an in-depth understanding of shared IL in nursing. We will select nursing leadership teams on 2 inpatient hospital units that have successfully implemented an EBP as instrumental cases. We will construct data through focus groups and individual interviews with key informants (leaders, unit staff, and senior nurse leaders), review of organizational documents, and researcher-generated field notes. We have developed a conceptual framework of shared IL to guide data analysis, which describes effective IL behaviors, formal and informal nursing leaders' roles at the POC, and social processes generating shared leadership and influencing contextual factors. We will use the Framework Method to systematically generate data matrices from deductive and inductive thematic analysis of each case. We will then generate assertions about shared IL following a cross-case analysis.

RESULTS

The study protocol received research ethics approval (2022-8408) on February 24, 2022. Data collection began in June 2022, and we have recruited 2 inpatient hospital units and 25 participants. Data collection was completed in December 2023, and data analysis is ongoing. We anticipate findings to be published in a peer-reviewed journal by late 2024.

CONCLUSIONS

The anticipated results will shed light on how multiple and diverse members of the POC nursing leadership team enact and share IL. This study addresses calls to advance knowledge in promoting effective implementation of EBPs to ensure high-quality health care delivery by further developing the concept of shared IL in a nursing context. We will identify strategies to strengthen shared IL in nursing leadership teams at the POC, informing future intervention studies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54681.

International Standards for Dementia Workforce Education and Training: A Scoping Review

BACKGROUND AND OBJECTIVES

The increasing number of people with dementia requires transparency and quality dementia education, training, and care. This scoping review aimed to determine the key elements of national or state-wide standards on dementia education and training that could underpin the development of international standards for dementia workforce training and education.

RESEARCH DESIGN AND METHODS

The English-language peer-reviewed and gray literature were searched (2010-20). Key search domains were training, workforce, standards/frameworks, and dementia.

RESULTS

Thirteen standards were identified from the United Kingdom (n = 5), the United States (n = 4), Australia (n = 3), and Ireland (n = 1). Most standards focused on training health care professionals with some including people in customer-centric settings, people living with dementia, and informal carers or the general community. Seventeen training topics were identified in 10 or more of the 13 standards. Cultural safety, rural issues, health care professional self-care, digital literacy, and health promotion topics were less commonly reported. The barriers to standards implementation were lack of organizational support, lack of access to relevant training, low staff literacy, lack of funding, high staff turnover, ineffective past program cycles, and inconsistent service delivery. Enablers included a strong implementation plan, funding, strength of partnerships, and building on previous work.

DISCUSSION AND IMPLICATIONS

The U.K. Dementia Skills and Core Training Standard, the Irish Department of Health Dementia Together, and the National Health Services Scotland Standard are the recommended strongest standards for underpinning the development of international standards. It is essential that training standards are tailored to the needs of the consumer, worker, and regions.

Selection of criteria for a telemedicine framework for designing, implementing, monitoring and evaluating telemedicine interventions: Validation using a modified Delphi process

Objectives

The call to scale up telemedicine services globally as part of the digital health transformation lacks an agreed-upon set of constructs to guide the implementation process. A lack of guidance hinders the development, consolidation, sustainability and optimisation of telemedicine services. The study aims to reach consensus among telemedicine experts on a set of implementation constructs to be developed into an evidence-based support tool.

Methods

A modified Delphi study was conducted to evaluate a set of evidence-informed telemedicine implementation constructs comprising cores, domains and items. The study evaluated the constructs consisting of five cores: Assessment of the Current Situation, Development of a Telemedicine Strategy, Development of Organisational Changes, Development of a Telemedicine Service, and Monitoring, Evaluation and Optimisation of Telemedicine Implementation; seven domains: Individual Readiness, Organisational Readiness, Clinical, Economic, Technological and Infrastructure, Regulation, and Monitoring, Evaluation and Optimisation; divided into 53 items. Global telemedicine specialists (n = 247) were invited to participate and evaluate 58 questions. Consensus was set at ≥70%.

Results

Forty-five experts completed the survey. Consensus was reached on 78% of the constructs evaluated. Regarding the core constructs, Monitoring, Evaluation and Optimisation of Telemedicine Implementation was determined to be the most important one, and Development of a Telemedicine Strategy the least. As for the domains, the Clinical one had the highest level of consensus, and the Economic one had the lowest.

Conclusions

This research advances the field of telemedicine, providing expert consensus on a set of implementation constructs. The findings also highlight considerable divergence in expert opinion on the constructs of reimbursement and incentive mechanisms, resistance to change, and telemedicine champions. The lack of agreement on these constructs warrants attention and may partly explain the barriers that telemedicine services continue to face in the implementation process.

Champion and audit and feedback strategy fidelity and their relationship to depression intervention fidelity: A mixed method study

Background

Globally, mental health disorders rank as the greatest cause of disability. Low and middle-income countries (LMICs) hold a disproportionate share of the mental health burden, especially as it pertains to depression. Depression is highly prevalent among those with non-communicable diseases (NCDs), creating a barrier to successful treatment. While some treatments have proven efficacy in LMIC settings, wide dissemination is challenged by multiple factors, leading researchers to call for implementation strategies to overcome barriers to care provision. However, implementation strategies are often not well defined or documented, challenging the interpretation of study results and the uptake and replication of strategies in practice settings. Assessing implementation strategy fidelity (ISF), or the extent to which a strategy was implemented as designed, overcomes these challenges. This study assessed fidelity of two implementation strategies (a 'basic' champion strategy and an 'enhanced' champion + audit and feedback strategy) to improve the integration of a depression intervention, measurement based care (MBC), at 10 NCD clinics in Malawi. The primary goal of this study was to assess the relationship between the implementation strategies and MBC fidelity using a mixed methods approach.

Methods

We developed a theory-informed mixed methods fidelity assessment that first combined an implementation strategy specification technique with a fidelity framework. We then created corresponding fidelity indicators to strategy components. Clinical process data and one-on-one in-depth interviews with 45 staff members at 6 clinics were utilized as data sources. Our final analysis used descriptive statistics, reflexive-thematic analysis (RTA), data merging, and triangulation to examine the relationship between ISF and MBC intervention fidelity.

Results

Our mixed methods analysis revealed how ISF may moderate the relationship between the strategies and MBC fidelity. Leadership engagement and implementation climate were critical for clinics to overcome implementation barriers and preserve implementation strategy and MBC fidelity. Descriptive statistics determined champion strategy fidelity to range from 61 to 93% across the 10 clinics. Fidelity to the audit and feedback strategy ranged from 82 to 91% across the 5 clinics assigned to that condition. MBC fidelity ranged from 54 to 95% across all clinics. Although correlations between ISF and MBC fidelity were not statistically significant due to the sample of 10 clinics, associations were in the expected direction and of moderate effect size. A coefficient for shared depression screening among clinicians had greater face validity compared to depression screening coverage and functioned as a proximal indicator of implementation strategy success.

Conclusion

Fidelity to the basic and enhanced strategies varied by site and were influenced by leadership engagement and implementation climate. Champion strategies may benefit from the addition of leadership strategies to help address implementation barriers outside the purview of champions. ISF may moderate the relationship between strategies and implementation outcomes.

Systematic review of health literacy champions: who, what and how?

Health literacy is an important aspect of equitable, safe, and high-quality care. For organizations implementing health literacy initiatives, using 'change champions' appears to be a promising strategy. This systematic review aimed to identify the empirical and conceptual research that exists about health literacy champions. We conducted the systematic literature search using MEDLINE, Embase, CINAHL, Scopus, and PubMed, with additional studies identified by searching references and citations of included studies and reviews of organizational health literacy. Seventeen articles were included in the final review (case studies, n = 9; qualitative research, n = 4; quasi-experimental, n = 2; opinion articles without case studies, n = 2). Using JBI critical appraisal tools, most articles had a high risk of bias. Often champions were not the focus of the article. Champions included staff across frontline, management, and executive levels. Only five studies described training for champions. Key champion activities related to either (i) increasing organizational awareness and commitment to health literacy, or (ii) influencing organizational strategic and operational planning. The most common output was ensuring that the organization's health information materials met health literacy guidelines. Articles recommended engaging multiple champions at varying levels within the organization, including the executive level. Limited funding and resources were key barriers. Two of four articles reported positive impacts of champions on implementation of health literacy initiatives. Overall, few of the articles described health literacy champions in adequate detail. More comprehensive reporting on this implementation strategy and further experimental and process evaluation research are needed to progress this area of research. This systematic review was registered with PROSPERO (CRD42022348816).

Using Project ECHO to Keep Professionals Well at Work: Individual and Organizational Outcomes

OBJECTIVE

The toll of COVID-19 stress on the mental health of the workforce has been well-documented. The present study examined the use of the Project ECHO framework to provide practices and resources on stress management and emotion regulation to increase individual and organizational health and well-being.

METHODS

Three independent ECHOs were designed and conducted over an 18-month period. Data was collected on the implementation of new learning and comparisons of organizational efforts toward being more secondary trauma responsive from baseline to post initiative, using cloud-based survey methods.

RESULTS

Findings suggest that the use of micro-interventions at the organizational level improved over time in the areas of resilience-building and policy-making, and that individuals were actively integrating skills related to managing their stress.

CONCLUSIONS

Lessons learned adapting and implementing ECHO strategies in the midst of a pandemic are offered, as well as how to cultivate wellness champions in the workforce.

Implementing school-wide sexual assault prevention in middle schools: A qualitative analysis of school stakeholder perspectives

Sexual assault and harassment are significant problems that begin early in the lifespan. The current study sought to understand the contextual factors that influence the implementation of school-wide sexual assault prevention programs in middle schools that focus on fostering community norms change. The Consolidated Framework for Implementation Research (CFIR) is a menu of constructs arranged across 5 domains that assists stakeholders in assessing and identifying site-specific determinants of successful intervention implementation. In the present study, researchers conducted a series of 10 interviews with middle school stakeholders (i.e., principals, guidance counselors, teachers) to document characteristics inside and outside of the school environment (i.e., cultural norms, relative priority, prior interventions, implementation climate) relevant to the implementation of prevention programming, using the CFIR as a guiding framework for analysis. Whereas schools recognized the importance of implementing violence prevention programming, stakeholders reported several other competing demands (i.e., time, resources) that make it difficult to implement rigorous programming without support from an outside agency/team. Community agencies and research teams hoping to implement violence prevention in middle schools can benefit from using stakeholder interviews grounded in the CFIR model to gain a better awareness of the school- and community-specific factors that are likely to influence successful implementation of violence prevention programs in middle schools.

The role of secondary traumatic stress breakthrough champions in reducing worker trauma and improving organizational health using a configurational analysis approach

Background

Emerging research has demonstrated that organizational efforts at becoming secondary traumatic stress (STS)-informed can improve the overall well-being of the workforce, especially when implementation activity by a champion team is high. Questions remain, however, regarding the mechanisms that enable these improvements.

Method

This study uses configurational analysis to determine necessary and sufficient conditions to produce reductions in STS symptoms in workers as well as organizational improvements toward being more STS-informed in a cohort survey of 6,033 professionals working with individuals exposed to trauma representing 52 organizations. The Secondary Traumatic Stress Informed Organizational Assessment (STSI-OA) was used to measure professional's perceptions of how well the unit addressed secondary trauma in the workplace, and the Secondary Traumatic Stress Scale (STSS) assessed traumatic stress symptoms in respondents. Champions' activity was scored using the categories suggested by Shea.

Results

For the STSS outcome, either a STSI-OA positive increase of 10 or more points or high levels of champion problem-solving were independently sufficient for an improvement in the outcome. The STSI-OA model had two pathways: high levels of peer engagement via the scaling up of innovations using PDSAs or the combination of facilitation of peer knowledge and skills together with working in a child welfare organization. Either pathway was sufficient by itself to yield the STSI-OA outcome.

Conclusions

Identifying and cultivating the champions' use of problem-solving and peer engagement strategies can transform the threat posed by indirect trauma exposure into an opportunity for shared experience and healing.

Plain Language Summary

Organizational champions are individuals or teams that strive to promote change within their workplace. These champions are integral to spreading innovative ideas and strategies and creating organization-wide changes ( Powell et al., 2015). However, little is known about the processes or specific strategies that make champions successful. One area in which champions are needed is in improving organizations' response to and understanding of secondary traumatic stress (STS), among those in helping professions that are indirectly exposed to trauma through the traumatic stories of those they work with. In fact, research has shown that organizational efforts to address STS improve the well-being of individual professionals within that organization ( Sprang et al., 2021). The present study sought to better understand what champion-related processes or conditions led to organizational change in addressing the effects of indirect exposure and improving symptoms related to STS. Results showed that organizational change in addressing STS and champions' problem-solving strategies resulted in reductions in individual professionals' STS symptoms. Furthermore, champions' use of peer engagement or sharing of knowledge among peers in child welfare settings led to improvements at an organizational level. These results show that organization-level change can have a direct impact on individual well-being and there are specific champion activities that can promote this change. Specifically, results demonstrate a need to identify and support champions' use of problem-solving and peer engagement strategies to turn the individual and organizational threat posed by indirect trauma into an opportunity for shared healing.

Place-Based Bias in Environmental Scholarship Derived from Social-Ecological Landscapes of Fear

Historical perspectives (e.g., moments of social, political, and economic significance) are increasingly relevant for developing insights into landscape change and ecosystem degradation. However, the question of how to incorporate historical events into ecological inquiry is still under development, owing to the evolving paradigm of transdisciplinary thinking between natural science and the humanities. In the present article, we call for the inclusion of negative human histories (e.g., evictions of communities and environmental injustices) as important factors that drive landscape change and shape research questions relevant to environmental conservation. We outline the detrimental effects of conservationists not addressing negative human histories by likening this social phenomenon to the ecological concept of landscapes of fear, which describes how not acknowledging these histories produces a landscape that constrains where and how research is conducted by scientists. Finally, we provide three positive recommendations for scholars or practitioners to address the manifestation of historic place-based bias in ecological research. What we call the social-ecological landscapes of fear provides a conceptual framework for more inclusive practices in ecology to increase the success of environmental and conservation goals.

Using implementation strategies in community settings: an introduction to the Expert Recommendations for Implementing Change (ERIC) compilation and future directions

In this commentary, we introduce public health practitioners and researchers to implementation science through an established compilation of implementation strategies. We provide terminology and examples for community settings so public health practitioners and researchers can use implementation strategies and document efforts using standard terminology. We also discuss the need for future work to determine the extent to which these implementation strategies work and are most useful in community settings, and ultimately, how health behaviors are impacted. We intend this commentary to serve as a dissemination strategy for implementation strategies and to contribute to knowledge in the growing field of implementation science in community settings.

Understanding the Role of Clinical Champions and Their Impact on Clinician Behavior Change: The Need for Causal Pathway Mechanisms

Background

The clinical champion approach is a highly utilized implementation strategy used to mitigate barriers and improve outcomes of implementation efforts. Clinical champions are particularly effective at addressing provider-level barriers and promoting provider-behavior change. Yet, the specific causal pathways that explain how clinical champions impact provider behavior change have not been well-explicated. The current paper applies behavior change models to develop potential causal pathway mechanisms.

Methods

The proposed mechanisms are informed by previous literature involving clinical champions and empirically supported behavior change models. These models are applied to link specific attributes to different stages of behavior change and barriers for providers.

Results

Two unique pathway mechanisms were developed, one that explicates how providers develop intention to use EBPs, while the other explicates how providers transition to EBP use and sustainment. Clinical champions may promote intention development through behavioral modeling and peer buy-in. In contrast, champions promote behavioral enactment through skill building and peer mentorship.

Conclusion

Clinical champions likely play a critical role in reducing provider implementation barriers for providers across various phases of behavior change. The proposed pathways provide potential explanations for how clinical champions promote provider behavior change. Future research should prioritize empirically testing causal pathway mechanisms.

Making implementation science more real

Implementation science in healthcare aims to understand how to get evidence into practice. Once this is achieved in one setting, it becomes increasingly difficult to replicate elsewhere. The problem is often attributed to differences in context that influence how and whether implementation strategies work. We argue that realist research paradigms provide a useful framework to express the effect of contextual factors within implementation strategy causal processes. Realist studies are theory-driven evaluations that focus on understanding how and why interventions work under different circumstances. They consider the interaction between contextual circumstances, theoretical mechanisms of change and the outcomes they produce, to arrive at explanations of conditional causality (i.e., what tends to work, for whom, under what circumstances). This Commentary provides example applications using preliminary findings from a large realist implementation study of system-wide value-based healthcare initiatives in New South Wales, Australia. If applied judiciously, realist implementation studies may represent a sound approach to help optimise delivery of the right care in the right setting and at the right time.

The role of trained champions in sustaining and spreading nutrition care improvements in hospital: qualitative interviews following an implementation study

BACKGROUND

Many patients are already malnourished when admitted to hospital. Barriers and facilitators to nutrition care in hospital have been identified and successful interventions developed; however, few studies have explored how to sustain and spread improvements. The More-2-Eat phase 1 study involved five hospitals across Canada implementing nutrition care improvements, while phase 2 implemented a scalable model using trained champions, audit and feedback, a community of practice with external mentorship and an implementation toolkit in 10 hospitals (four continuing from phase 1). Process measures showed that screening and assessment from phase 1 were sustained for at least 4 years. The objective of this study was to help explain how these nutrition care improvements were sustained and spread by understanding the role of the trained champions, and to confirm and expand on themes identified in phase 1.

METHODS

Semistructured telephone interviews were conducted with champions from each phase 2 hospital and recordings transcribed verbatim. To explore the champion role, transcripts were deductively coded to the 3C model of Concept, Competence and Capacity. Phase 2 transcripts were also deductively coded to themes identified in phase 1 interviews and focus groups.

RESULTS

Ten interviews (n=14 champions) were conducted. To sustain and spread nutrition care improvements, champions needed to understand the Concepts of change management, implementation, adaptation, sustainability and spread in order to embed changes into routine practice. Champions also needed the Competence, including the skills to identify, support and empower new champions, thus sharing the responsibility. Capacity, including time, resources and leadership support, was the most important facilitator for staying engaged, and the most challenging. All themes identified in qualitative interviews in phase 1 were applicable 4 years later and were mentioned by new phase 2 hospitals. There was increased emphasis on audit and feedback, and the need for standardisation to support embedding into current practice.

CONCLUSION

Trained local champions were required for implementation. By understanding key concepts, with appropriate and evolving competence and capacity, champions supported sustainability and spread of nutrition care improvements. Understanding the role of champions in supporting implementation, spread and sustainability of nutrition care improvements can help other hospitals when planning for and implementing these improvements.

TRIAL REGISTRATION NUMBER

NCT02800304, NCT03391752.

Bridging institutional logics: Implementing naloxone distribution for people exiting jail in three California counties

Drug overdose is the leading cause of death among formerly incarcerated people. Distribution of the opioid overdose medication naloxone to people who use drugs reduces overdose mortality, and officials in many jurisdictions are now considering or implementing programs to offer naloxone to people exiting jails and prisons. The principles and practices of harm reduction programs such as naloxone distribution conflict with those of penal institutions, raising the question of how organizations based on opposing institutional logics can collaborate on lifesaving programs. Using in-depth interviews and observations conducted over four years with 34 penal, medical, public health, and harm reduction practitioners, we introduce and conceptualize two organizational features to explain why this therapeutic intervention was implemented in local jails in two of three California counties. First, interorganizational bridges between harm reduction, medical, and penal organizations facilitated mutual understanding and ongoing collaboration among administrators and frontline workers in different agencies. Second, respected and influential champions within public health and penal organizations put jail-based naloxone distribution on the local agenda and cultivated support among key officials. Our findings offer guidance for future studies of institutional logics and policy responses to the overdose crisis.