Building theories of knowledge translation interventions: use the entire menu of constructs

Evidence-informed stakeholder consultations to promote rights-based approaches for children with disabilities

Purpose

To strengthen the translation of evidence to actionable policy, stakeholder engagement is necessary to synthesize, prioritize and contextualize the academic research content into accessible language. In this manuscript we describe a multi-level evidence-based stakeholder consultation process and related outcomes proposed to promote awareness of and foster cross-sectorial collaborations towards human rights-based approaches for children with disabilities.

Methods

Mixed-methods participatory action research done in three steps: (1) A literature review of peer-reviewed evidence on rights-based approaches in childhood disabilities; (2) Consultation with researchers in diverse fields, grassroot organizations, caregivers, and youth with disabilities; (3) A constructive dialogue with decision makers at federal and provincial levels in Canada to discuss consultations results.

Results

Stakeholders value human rights approaches that can have a direct impact on practical aspects of their daily living. Organizations give high importance to adopting rights-based approaches to measure policy outcomes, while parents value service provision and youth emphasize accessibility.

Conclusion

The implementation of rights-based approaches in childhood disabilities can support policy, services, and daily lives of children with disabilities and the ecosystems around them. It can also guide research priorities, and create a common language to foster collaborations across sectors and interested parties.

Clinical Remote Monitoring of Individuals With Spinal Cord Injury at Risk for Pressure Injury Recurrence Using mHealth: Protocol for a Pilot, Pragmatic, Hybrid Implementation Trial

BACKGROUND

Pressure injuries are one of the most challenging secondary conditions for individuals with spinal cord injuries and related disorders (SCI/D) owing to inherent, lifelong risk factors that include a lack of sensory and motor function below the level of injury and reliance on a wheelchair for daily mobility, resulting in prolonged periods of sitting. Although many factors contribute to the development of pressure injuries, the pressure between the skin and a surface is always a factor and the development of injury is dependent on the magnitude and duration of the pressure. Clinically, broad recommendations for relieving pressure are used because we know very little about the unique day-to-day life patterns of the individual wheelchair user. Typically, it is after the occurrence of a pressure injury that the therapist will check equipment fit and the effectiveness of pressure offloading and ask about other surfaces they sit on in their home and community. This time-lapsed, largely self-reported data are fraught with recall bias and inaccuracies that the therapist incorporates into a plan of care.

OBJECTIVE

This study's objective is to pilot-test the implementation and clinical effectiveness of a telehealth model of care combined with our mobile health (mHealth) Assisted Weight-Shift device for remote monitoring of factors related to maintaining skin health and wheelchair setup. Our overall hypothesis is that this study will result in an effective implementation plan, and the enhanced connected model of care using remote monitoring of pressure management will result in pilot-level, improved clinical outcomes for adults with spinal cord injury at high risk for pressure injury recurrence.

METHODS

For all aims, we will use a mixed methods design using an exploratory, sequential approach to include the strengths of both qualitative and quantitative data. For aims 1 and 2, we will iteratively collect qualitative data from therapists, patients with SCI/D, and other stakeholders. For aim 3, we will perform a hybrid effectiveness-implementation randomized controlled trial to pilot-test the intervention. The projected results include an iteratively developed and tested implementation plan that meets moderate to high levels of acceptability, feasibility, and appropriateness. Additionally, the pilot trial results are expected to show positive trends in relevant clinical outcomes related to reduced pressure injury incidence, recurrence, and improved healing when compared with the standard of care.

RESULTS

Currently, 6 participants have been recruited for our aim-1 qualitative study.

CONCLUSIONS

This study will expand upon our previous study to move the Assisted Weight-Shift system into routine clinical care, which was a strong desire of adults with SCI/D for improved individualized care plans to prevent pressure injuries. The results of this study will guide the next steps in a full, hybrid effectiveness-implementation trial with the goal of improving care to prevent pressure injuries.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51849.

Using normalization process theory to inform practice: evaluation of a virtual autism training for clinicians

Background

There is growing demand for developmental and behavioral pediatric services including autism evaluation and care management. Clinician trainings have been found to result in an increase of knowledge and attitudes. This study utilizes Normalization Process theory (NPT) to evaluate a clinician training program and its effects on practice.

Methods

The year-long virtual training program about autism screening and care management included didactic portions and case presentations. Focus groups and interviews were conducted with primary care clinicians (n = 10) from community health centers (n = 6) across an urban area five months post-training. Transcripts were deductively coded using NPT to uncover barriers to implementation of autism screening and care, benefits of the training program, and areas for future training.

Results

Participants were motivated by the benefits of expanding and improving support for autistic patients but noted this effort requires effective collaboration within a complex network of care providers including clinicians, insurance agencies, and therapy providers. Although there were support that participants could provide to families there were still barriers including availability of behavior therapy and insufficient staffing. Overall, participants positively viewed the training and reported implementing new strategies into practice.

Conclusion

Despite the small sample size, application of NPT allowed for assessment of both training delivery and implementation of strategies, and identification of recommendations for future training and practice sustainability. Follow-up focus groups explored participants' practice five months post-program. Variations in participants' baseline experience and context at follow-up to enable application of skills should be considered when using NPT to evaluate clinician trainings.

Youth intentions to provide social support to a peer with a concussion

OBJECTIVES

1) To describe demographic factors, concussion knowledge, attitudes, subjective norms, self-efficacy and intentions to provide social support to a peer with a concussion and 2) to examine if demographic factors and concussion knowledge are associated with components of the Theory of Planned Behavior.

METHODS

The survey was completed between October 2018 and February 2019 by 200 youth (M = 15.30 years, SD = 1.52). Questions were designed for athletes and non-athletes and inquired about various types of social support. Data analysis included descriptive statistics, Wilcoxon Rank Sum Tests and Spearman's Rank-Order Correlation Coefficients.

RESULTS

More favorable attitudes and intentions to provide social support were observed among females (W = 2576, p ≤ 0.001; W = 2411, p ≤ 0.001), older youth (rho = 0.32, p ≤ 0.001; rho = 0.41, p ≤ 0.001) and those with higher concussion knowledge (rho = 0.29, p ≤ 0.001; rho = 0.22; p ≤ 0.001). Participating in sports with a high-risk of concussion was associated with lower attitudes and intentions to provide social support (W = 6677; p ≤ 0.001; W = 6721; p ≤ 0.001). Self-reported concussion history or knowing someone with a concussion history was not significantly associated with social support intentions.

CONCLUSION

This study identified characteristics of youth who had positive intentions to provide social support. These findings identify individuals who may model providing social support to a peer, as well as opportunities for future concussion education.

Developing the intersectionality supplemented Consolidated Framework for Implementation Research (CFIR) and tools for intersectionality considerations

BACKGROUND

The concept of intersectionality proposes that demographic and social constructs intersect with larger social structures of oppression and privilege to shape experiences. While intersectionality is a widely accepted concept in feminist and gender studies, there has been little attempt to use this lens in implementation science. We aimed to supplement the Consolidated Framework for Implementation Research (CFIR), a commonly used framework in implementation science, to support the incorporation of intersectionality in implementation science projects by (1) integrating an intersectional lens to the CFIR; and (2) developing a tool for researchers to be used alongside the updated framework.

METHODS

Using a nominal group technique, an interdisciplinary framework committee (n = 17) prioritized the CFIR as one of three implementation science models, theories, and frameworks to supplement with intersectionality considerations; the modification of the other two frameworks are described in other papers. The CFIR subgroup (n = 7) reviewed the five domains and 26 constructs in the CFIR and prioritized domains and constructs for supplementation with intersectional considerations. The subgroup then iteratively developed recommendations and prompts for incorporating an intersectional approach within the prioritized domains and constructs. We developed recommendations and prompts to help researchers consider how personal identities and power structures may affect the facilitators and inhibitors of behavior change and the implementation of subsequent interventions.

RESULTS

We achieved consensus on how to apply an intersectional lens to CFIR after six rounds of meetings. The final intersectionality supplemented CFIR includes the five original domains, and 28 constructs; the outer systems and structures and the outer cultures constructs were added to the outer setting domain. Intersectionality prompts were added to 13 of the 28 constructs.

CONCLUSION

Through an expert-consensus approach, we modified the CFIR to include intersectionality considerations and developed a tool with prompts to help implementation users apply an intersectional lens using the updated framework.

'On-the ground' strategy matrix for fostering quality participation experiences among persons with disabilities in community-based exercise programs

OBJECTIVE

The purposes of this paper are to (1) document the generation and refinement of a quality participation strategy list to ensure resonance and applicability within community-based exercise programs (CBEPs) for persons with physical and intellectual disabilities, and (2) identify theoretical links between strategies and the quality participation constructs.

METHODS

To address purpose one, a list of strategies to foster quality participation among members was extracted from qualitative interviews with providers from nine CBEPs serving persons with physical disabilities. Next, providers from CBEPs serving persons with physical (n = 9) and intellectual disabilities (n = 6) were asked to identify the strategies used, and examples of their implementation, within their programs. Additional strategies noted by providers and in recent published syntheses were added to the preliminary list. A re-categorization and revision process was conducted. To address purpose two, 22 researchers with expertise in physical and/or intellectual disability, physical activity, participation and/or health behaviour change theory completed a closed-sort task to theoretically link each strategy to the constructs of quality participation.

RESULTS

The final list of 85 strategies is presented in a matrix. Each strategy has explicit examples and proposed theoretical links to the constructs of quality participation.

CONCLUSIONS

The strategy matrix offers a theoretically-meaningful representation of how quality participation-enhancing strategies can be practically implemented "on-the-ground" in CBEPs for persons with disabilities.

Qualitative Assessment of Key Implementation Factors in a Faith-Based Response to Intimate Partner Violence

BACKGROUND

Faith-based organizations (FBOs) have a scant history in the literature of implementing intimate partner violence (IPV) initiatives, though many members of faith communities consider it an important issue. Furthermore, the limited studies on this topic have not explored organizational factors that are important in the implementation of such efforts.

PURPOSE

To investigate factors that influence the implementation of IPV prevention and response by one Catholic organization at both diocesan and parish levels.

METHODS

We conducted sixteen semi-structured interviews with members of Archdiocese of Chicago Domestic Violence Outreach (ACDVO) leadership. Using deductive content analysis, we drew on all 14 constructs and sub-constructs from the inner setting domain of the Consolidated Framework for Implementation Research (CFIR) for coding transcripts and characterizing factors influencing implementation success.

RESULTS

Seven CFIR constructs were useful in identifying factors that influenced implementation success of ACDVO. At the diocesan level, the organization's leadership structure, their driven culture, and in-kind available resources propelled their work. At the level of parish ministries, successful implementation was facilitated by networking and communication among parishes. At the diocesan-level, access to knowledge and information through ACDVO's Parish Support Committee, compatibility with parish values, leadership engagement, and available resources from parishes supported implementation.

CONCLUSIONS

We identified modifiable and reproducible inner setting factors that influence implementation of a Catholic IPV initiative at the diocesan-level and support parish ministries in their local activities. Future work should validate these findings in other dioceses and examine non-Catholic FBO settings.

Improving Knowledge of Audit and Feedback among Health Care Professionals in Sicily

Audit and Feedback (A&F) is considered one of the most significant tools for implementing continuous Quality Improvement (QI) in the healthcare field. The audit process is a structured inspection of professional practice against known standards or targets. The results of this inspection are subsequently feedback from professionals in order to implement an improvement process. The Italian Ministry of Health has recently funded the network project EASY-NET, with the main objective of evaluating the effectiveness of A&F strategies to improve healthcare practice and equity in various clinical and organizational settings in seven Italian regions. The Sicily region is represented within the EASY-NET project by the IRCCS Centro Neurolesi Bonino-Pulejo of Messina as the Work Package 7 (WP7). One of the objectives of the WP7 is to assess mechanisms and tools to enhance the effectiveness of A&F strategies. The purpose of this study is to investigate the influence that training interventions can have on improving knowledge of A&F strategies among healthcare professionals. The study employed a quasi-experimental design with a pretest-posttest evaluation strategy. The participants' initial knowledge of A&F strategies was evaluated through a baseline survey. Subsequently, the participants attended an online training workshop led by A&F experts, and a follow-up survey consisting of the same set of questions was conducted at the end of the process. Results showed statistically significant positive changes in the level of knowledge of A&F among participants following the training intervention. Furthermore, dividing the participants into two subgroups based on their professional background revealed significant differences in the level of knowledge of A&F methodologies between the observed categories of healthcare professionals. In conclusion, the study revealed that training interventions can be facilitators to implementing effective A&F programs.

Primary care asthma surveillance: a review of knowledge translation tools and strategies for quality improvement

BACKGROUND

Viable knowledge translation (KT) strategies are increasingly sought to improve asthma diagnosis, particularly in primary care. Despite this understanding, practical KT tools to support primary care practitioners are not widely available. Electronic medical records (EMRs) offer an opportunity to optimize the diagnosis and surveillance of chronic diseases such as asthma, and support quality improvement initiatives that increase adherence to guideline-recommended care. This review aims to describe the current state of electronic KT electronic tools (eTools) and surveillance systems for asthma and identify opportunities to increase adherence to asthma diagnostic guidelines by implementing digital KT eTools.

METHODS

Systematic literature searches were conducted on Ovid MEDLINE that included the search terms: asthma, asthma diagnosis, asthma surveillance, electronic health records, translational medical research, quality improvement, professional practice gaps, and primary health care published in the previous 10 years. In total, the searches returned 971 articles, 163 of which were considered relevant and read in full. An additional 28 articles were considered after reviewing the references from selected articles. 75 articles were included in this narrative review.

RESULTS

Established KT eTools for asthma such as electronic questionnaires, computerized clinical decision support systems (CDSS), chronic disease surveillance networks, and asthma registries have been effective in improving the quality of asthma diagnosis and care. As well, chronic disease surveillance systems, severe asthma registries, and workplace asthma surveillance systems have demonstrated success in monitoring asthma outcomes. However, lack of use and/or documentation of objective measures of lung function, challenges in identifying asthma cases in EMRs, and limitations of data sources have created barriers in the development of KT eTools. Existing digital KT eTools that overcome these data quality limitations could provide an opportunity to improve adherence to best-practice guidelines for asthma diagnosis and management.

CONCLUSION

Future initiatives in the development of KT eTools for asthma care should focus on strategies that assist healthcare providers in accurately diagnosing and documenting cases of asthma. A digital asthma surveillance system could support adherence to best-practice guidelines of asthma diagnosis and surveillance by prompting use of objective methods of confirmation to confirm an asthma diagnosis within the EMR.

Making sense of adaptive expertise for frontline clinical educators: a scoping review of definitions and strategies

Adaptive expertise has been promoted as an emerging model of expertise in health professions education in response to the inherent complexities of patient care; however, as the concept increasingly influences the structure of professional training and practice, it creates the potential for misunderstandings of the definition and implications of adaptive expertise. To foster a common understanding of the concept, we conducted a scoping review to explore how adaptive expertise has been discussed within health professions education literature. Five databases-MedLine, PubMed, ERIC, CINAHL, and PsycINFO-were searched using the exact term "adaptive expertise", producing 212 unique articles. Fifty-eight articles met inclusion criteria. In the included articles, authors discussed the conceptual implications of adaptive expertise for health professions education, strategies for training for adaptive expertise, and research findings aimed at supporting the development of adaptive expertise or utilizing adaptive expertise as a theoretical framework. The goal of this scoping review is to establish a resource for frontline educators tasked with fostering the development of adaptive expertise in learners through education initiatives. A common understanding of adaptive expertise is essential to ensuring effective implementation in training programs.

The Influence of Health Behavior Theory on Implementation Practice and Science: Brief Review and Commentary

As research defines new treatments and policies to improve the health of patients, an increasing challenge has been to translate these insights into routine clinical practice to benefit patients and society. An important exploration is how theories of human behavior change fit into the science of implementation and quality improvement. In this paper, we begin with a brief review of the intellectual roots of implementation science and quality improvement, followed by a discussion of how theories and principles of behavior change can inform both goals and challenges in using behavior change theories. The insights offered through health behavior change theory have led to changes in how we plan for implementation and select, develop, design and tailor implementation interventions and strategies. While the degree to which organizational and external contexts influence the behavior of providers in these organizations varies widely, some degree of context external to the individual is important and needs adequate consideration. In short, health behavior change theory is essential but not sufficient to integrate in most implementation efforts, where priority must be given to both individual factors and contexts in which individuals operate.

Audit and feedback in cardio- and cerebrovascular setting: Toward a path of high reliability in Italian healthcare

Adopting audit and feedback (A&F) strategies could be a suitable healthcare intervention to fulfill the challenge of monitoring and improving clinical guidelines in evidence-based medicine. Indeed, A&F is used to encourage professionals to better adhere to standard guidelines to improve healthcare performance. Briefly, an audit is an inspection of professional practice in comparison to professional standards or targets whose results are subsequently communicated to professionals in a structured manner. Although A&F strategies have been adopted in several time-dependent settings, such as for acute myocardial infarction (AMI) and stroke, interest of audits in rehabilitation care is also emerging. Recently, the Italian Ministry of Health has funded a national network project called EASY-NET, whose main objective is to evaluate the effectiveness of A&F strategies to improve healthcare practice and equity in various clinical and organizational settings in seven Italian regions. Last but not the least of these regions is the Sicily, represented within the project by the IRCCS Centro Neurolesi Bonino-Pulejo of Messina as the work package 7 (WP7). The EASY-NET WP7 is focused on the effectiveness of A&F strategies in both AMI and ischemic stroke setting, from acute to rehabilitation process of care. In this study, we described the study protocol, including the study design and methodology, providing a detailed description of the new model of A&F based on telemedicine, and discussing the possible challenges of this project.

Healthcare professional behaviour: health impact, prevalence of evidence-based behaviours, correlates and interventions

Healthcare professional (HCP) behaviours are actions performed by individuals and teams for varying and often complex patient needs. However, gaps exist between evidence-informed care behaviours and the care provided. Implementation science seeks to develop generalizable principles and approaches to investigate and address care gaps, supporting HCP behaviour change while building a cumulative science. We highlight theory-informed approaches for defining HCP behaviour and investigating the prevalence of evidence-based care and known correlates and interventions to change professional practice. Behavioural sciences can be applied to develop implementation strategies to support HCP behaviour change and provide valid, reliable tools to evaluate these strategies. There are thousands of different behaviours performed by different HCPs across many contexts, requiring different implementation approaches. HCP behaviours can include activities related to promoting health and preventing illness, assessing and diagnosing illnesses, providing treatments, managing health conditions, managing the healthcare system and building therapeutic alliances. The key challenge is optimising behaviour change interventions that address barriers to and enablers of recommended practice. HCP behaviours may be determined by, but not limited to, Knowledge, Social influences, Intention, Emotions and Goals. Understanding HCP behaviour change is a critical to ensuring advances in health psychology are applied to maximize population health.

Efficacy of a theory-driven program to implement alcohol screening and brief interventions in primary health-care: a cluster randomized controlled trial

BACKGROUND AND AIMS

Screening and brief interventions (SBI) in primary health-care practices (PHCP) are effective in reducing reported alcohol consumption, but have not been routinely implemented. Most programs seeking to improve implementation rates have lacked a theoretical rationale. This study aimed to test whether a theory-based intervention for PHCPs could significantly increase alcohol SBI delivery.

DESIGN

Two-arm, cluster-randomized controlled, parallel, 12-month follow-up, trial.

SETTING

PHCPs in Portugal.

PARTICIPANTS

Staff from 12 PHCPs (n = 222, 81.1% women): nurses (35.6%), general practitioners (28.8%), receptionists (26.1%) and family medicine residents (9.5%); patients screened for alcohol use: intervention n = 8062; controls n = 58.

INTERVENTION AND COMPARATOR

PHCPs were randomized to receive a training and support program (n = 6; 110 participants) tailored to the barriers and facilitators for implementing alcohol SBIs following the principles of the Behavior Change Wheel/Theoretical Domains Framework approach, or to a waiting-list control (n = 6; 112 participants). Training was delivered over the first 12 weeks of the trial.

MEASUREMENTS

The primary outcome was the proportion of eligible patients screened (unit of analysis: patient list). Secondary outcomes included the brief intervention (BI) rate per screen-positive patient and the population-based BI rate (unit of analysis: patient list), and changes in health providers' perceptions of barriers to implementation and alcohol-related knowledge (unit of analysis: health provider).

FINDINGS

The implementation program had a significant effect on the screening activity in the intervention practices compared with control practices at the 12-month follow-up (21.7% vs. 0.16%, intention-to-treat analysis, p = 0.003). Although no significant difference was found on the BI rate per screen-positive patient (intervention 85.7% vs. control 63.6%, p = 0.55, Bayes factor = 0.28), the intervention was effective in increasing the population-based BI rate (intervention 0.69% vs. control 0.02%, p = 0.006). Health providers in the intervention arm reported fewer barriers to SBI implementation and higher levels of alcohol-related knowledge at 12-month follow-up than those in control practices.

CONCLUSION

A theory-based implementation program, which included training and support activities, significantly increased alcohol screening and population-based brief intervention rates in primary care.

A Scalable Service to Improve Health Care Quality Through Precision Audit and Feedback: Proposal for a Randomized Controlled Trial

BACKGROUND

Health care delivery organizations lack evidence-based strategies for using quality measurement data to improve performance. Audit and feedback (A&F), the delivery of clinical performance summaries to providers, demonstrates the potential for large effects on clinical practice but is currently implemented as a blunt one size fits most intervention. Each provider in a care setting typically receives a performance summary of identical metrics in a common format despite the growing recognition that precisionizing interventions hold significant promise in improving their impact. A precision approach to A&F prioritizes the display of information in a single metric that, for each recipient, carries the highest value for performance improvement, such as when the metric's level drops below a peer benchmark or minimum standard for the first time, thereby revealing an actionable performance gap. Furthermore, precision A&F uses an optimal message format (including framing and visual displays) based on what is known about the recipient and the intended gist meaning being communicated to improve message interpretation while reducing the cognitive processing burden. Well-established psychological principles, frameworks, and theories form a feedback intervention knowledge base to achieve precision A&F. From an informatics perspective, precision A&F requires a knowledge-based system that enables mass customization by representing knowledge configurable at the group and individual levels.

OBJECTIVE

This study aims to implement and evaluate a demonstration system for precision A&F in anesthesia care and to assess the effect of precision feedback emails on care quality and outcomes in a national quality improvement consortium.

METHODS

We propose to achieve our aims by conducting 3 studies: a requirements analysis and preferences elicitation study using human-centered design and conjoint analysis methods, a software service development and implementation study, and a cluster randomized controlled trial of a precision A&F service with a concurrent process evaluation. This study will be conducted with the Multicenter Perioperative Outcomes Group, a national anesthesia quality improvement consortium with >60 member hospitals in >20 US states. This study will extend the Multicenter Perioperative Outcomes Group quality improvement infrastructure by using existing data and performance measurement processes.

RESULTS

The proposal was funded in September 2021 with a 4-year timeline. Data collection for Aim 1 began in March 2022. We plan for a 24-month trial timeline, with the intervention period of the trial beginning in March 2024.

CONCLUSIONS

The proposed aims will collectively demonstrate a precision feedback service developed using an open-source technical infrastructure for computable knowledge management. By implementing and evaluating a demonstration system for precision feedback, we create the potential to observe the conditions under which feedback interventions are effective.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/34990.

Pushing the bench: A mixed methods study of barriers to and facilitators of identification and referral into depression care by professional nurses in KwaZulu-Natal, South Africa

OBJECTIVE

Integration of mental health and chronic disease services in primary care could reduce the mental health treatment gap and improve associated health outcomes in low-resource settings. Low rates of nurse identification and referral of patients with depression limit the effectiveness of integrated mental health care; the barriers to and facilitators of identification and referral in South Africa and comparable settings remain undefined. This study explored barriers to and facilitators of nurse identification and referral of patients with depressive symptoms as part of integrated mental health service delivery in KwaZulu-Natal, South Africa.

DESIGN

Triangulation mixed methods study incorporating qualitative and quantitative data.

METHODS

Data collection, analysis, and interpretation were guided by the Consolidated Framework for Implementation Research (CFIR). Participants were professional nurses at ten primary health care facilities in Amajuba, KwaZulu-Natal, South Africa. Qualitative data collection involved semi-structured interviews targeting specific CFIR constructs with high- and low-referring nurses. Deductive and inductive coding were used to derive primary themes related to barriers and facilitators. Quantitative data collection involved a structured questionnaire assessing determinants explored in the interviews. Qualitative comparative analysis was used to identify the necessary or sufficient conditions for high and low nurse referral.

RESULTS

Twenty-two nurses were interviewed. Primary themes related to insufficient training, supervision, and competency; emotional burden; limited human and physical resources; perceived patient need for integrated services; and intervention acceptability. Sixty-eight nurses completed questionnaires. Quantitative results confirmed and expanded upon the qualitative findings. Low self-assessed competency was a consistent barrier to appropriate service delivery.

CONCLUSIONS

To promote the success of integrated care in a context of severe staff shortages and over-burdened providers, implementation strategies including direct training, structured supervision, and routine behavioral health screening tools are warranted. Interventions to improve mental health literacy of patients as well as emotional support for nurses are also needed.

Leveraging knowledge translation and implementation science in the pursuit of evidence informed health professions education

Evidence informed approaches to health professions education can ensure accountability to learners and society in providing meaningful and effective education and helping resource strained systems via streamlined and cost-efficient practices. Knowledge translation and implementation science are two areas of study originally developed in clinical medicine in response to concerns that health care practices were incongruent with the scientific evidence. Two decades of research have led to important advances in our understanding of the nature and magnitude of research-practice gaps, the factors that support or impede adoption of evidence in clinical decision-making, and in the design and evaluation of theory driven interventions to reduce gaps. This paper borrows concepts from knowledge translation and implementation science to further our thinking about how health professions education can 'truly' be evidence informed. The article is organised in four sections: a discussion of the impetus for the evidence informed health professions education movement; a description of the origins of knowledge translation and implementation science; a discussion on how knowledge translation and implementation science can be leveraged to advance the evidence informed health professions education agenda; and suggestions for future discussion and research. An example is used to illustrate the application of the underpinning principles of knowledge translation and implementation science. The authors suggest a theory driven, staged and systematic approach that integrates knowledge translation principles and processes and involves key stakeholders interested in promoting the application of educational research of evidence.

Facilitating Guideline Implementation in Primary Health Care Practices

Introduction: Many patients continue to receive suboptimal services, inappropriate, unsafe, and costly care. Underutilization of research by health professionals is a common problem in the primary care setting. Although many theoretical frameworks can be used to help address such evidence-practice gaps, health care professionals may not be aware of the benefits of frameworks or of the most appropriate ones for their context and thus, may be faced with the challenge of selecting and using the most relevant one. Aim: The aim of this article was to describe the process used to adapt a knowledge translation framework to meet the local needs of health professionals working in one large primary care setting. Methods: The authors developed a 5-step approach for guideline implementation. This approach was informed by prior research and the authors’ experiences in supporting multidisciplinary teams of health care professionals during the implementation of evidence-based clinical guidelines into primary care practices. To ensure that the 5-step approach was practical and suitable for the context of guideline implementation by multidisciplinary teams in primary health care, the implementation team adapted the “knowledge-to-action” framework using a multistep process. Results: The implementation approach consisted of the following 5 steps: identification, context analysis, development of implementation plan, evaluation, and sustainability. All 5 steps were described alongside details about a national low back pain project. Discussion: This article describes a collaborative, grassroots process that addressed an identified need in one complex context by adapting a knowledge translation framework to meet the local needs of health professionals working in primary care settings. Existing implementation frameworks may be too complex or abstract for use in busy clinical contexts. The 5-step approach presented in this paper resulted in practical steps that are more readily understood by health care professionals and staff on “the ground.”

Barriers and enablers to effective interprofessional teamwork in the operating room: A qualitative study using the Theoretical Domains Framework

Background

Effective teamwork is critical for safe, high-quality care in the operating room (OR); however, teamwork interventions have not consistently resulted in the expected gains for patient safety or surgical culture. In order to optimize OR teamwork in a targeted and evidence-based manner, it is first necessary to conduct a comprehensive, theory-informed assessment of barriers and enablers from an interprofessional perspective.

Methods

This qualitative study was informed by the Theoretical Domains Framework (TDF). Volunteer, purposive and snowball sampling were conducted primarily across four sites in Ontario, Canada and continued until saturation was reached. Interviews were recorded, transcribed, and de-identified. Directed content analysis was conducted in duplicate using the TDF as the initial coding framework. Codes were then refined whereby similar codes were grouped into larger categories of meaning within each TDF domain, resulting in a list of domain-specific barriers and enablers.

Results

A total of 66 OR healthcare professionals participated in the study (19 Registered Nurses, two Registered Practical Nurses, 17 anaesthesiologists, 26 surgeons, two perfusionists). The most frequently identified teamwork enablers included people management, shared definition of teamwork, communication strategies, positive emotions, familiarity with team members, and alignment of teamwork with professional role. The most frequently identified teamwork barriers included others’ personalities, gender, hierarchies, resource issues, lack of knowledge of best practices for teamwork, negative emotions, conflicting norms and perceptions across professions, being unfamiliar with team members, and on-call/night shifts.

Conclusions

We identified key factors influencing OR teamwork from an interprofessional perspective using a theoretically informed and systematic approach. Our findings reveal important targets for future interventions and may ultimately increase their effectiveness. Specifically, achieving optimal teamwork in the OR may require a multi-level intervention that addresses individual, team and systems-level factors with particular attention to complex social and professional hierarchies.

Awareness of performance on outcomes after total hip and knee arthroplasty among Dutch orthopedic surgeons: how to improve feedback from arthroplasty registries

Background and purpose - The Netherlands Registry of Orthopedic Implants (LROI) uses audit and feedback (A&F) as the strategy to improve performance outcomes after total hip and knee arthroplasty (THA/TKA). Effectiveness of A&F depends on awareness of below-average performance to initiate improvement activities. We explored the awareness of Dutch orthopedic surgeons regarding their performance on outcomes after THA/TKA and factors associated with this awareness.Methods - An anonymous questionnaire was sent to all 445 eligible Dutch orthopedic surgeons performing THA/TKA. To assess awareness on own surgeon-group performance, they were asked whether their 1-year THA/TKA revision rates over the past 2 years were below average (negative outlier), average (non-outlier), above average (positive outlier) in the funnel plot on the LROI dashboard, or did not know. Associations were determined with (1) dashboard login at least once a year (yes/no); (2) correct funnel-plot interpretation (yes/no) and; (3) recall of their 1-year THA/TKA revision rate (yes/no).Results - 44% of respondents started the questionnaire, 158 THA and 156 TKA surgeons. 55% of THA surgeons and 55% of TKA surgeons were aware of their performance. Surgeons aware of their performance more often logged in on the LROI dashboard, more often interpreted funnel plots correctly, and more often recalled their revision rate. 38% of THA and 26% of TKA surgeons scored "good" on all 3 outcomes.Interpretation - Only half of the orthopedic surgeons were aware of their performance status regarding outcomes after THA/TKA. This suggests that to increase awareness, orthopedic surgeons need to be actively motivated to look at the dashboard more frequently and educated on interpretation of funnel plots for audit and feedback to be effective.

Factors influencing the implementation of screening and brief interventions for alcohol use in primary care practices: a systematic review using the COM-B system and Theoretical Domains Framework

BACKGROUND

Alcohol is a leading risk factor contributing to the global burden of disease. Several national and international agencies recommend that screening and brief interventions (SBI) should be routinely delivered in primary care settings to reducing patients' alcohol consumption. However, evidence shows that such activities are seldom implemented in practice. A review of the barriers and facilitators mediating implementation, and how they fit with theoretical understandings of behaviour change, to inform the design of implementation interventions is lacking. This study aimed to conduct a theory-informed review of the factors influencing general practitioners' and primary care nurses' routine delivery of alcohol SBI in adults.

METHODS

A systematic literature search was carried out in four electronic databases (Medline, CINAHL, CENTRAL, PsycINFO) using comprehensive search strategies. Both qualitative and quantitative studies were included. Two authors independently abstracted and thematically grouped the data extracted. The barriers and facilitators identified were mapped to the domains of the Capability-Opportunity-Motivation-Behaviour system/Theoretical Domains Framework (TDF).

RESULTS

Eighty-four out of the 258 studies identified met the selection criteria. The majority of the studies reported data on the views of general practitioners (n = 60) and used a quantitative design (n = 49). A total of 660 data items pertaining to barriers and 253 data items pertaining to facilitators were extracted and thematically grouped into 46 themes. The themes mapped to at least one of the 14 domains of the TDF. The three TDF domains with the highest number of data units coded were 'Environmental Context and Resources' (n = 158, e.g. lack of time), 'Beliefs about Capabilities' (n = 134, e.g. beliefs about the ability to deliver screening and brief advice and in helping patients to cut down) and 'Skills' (n = 99, e.g. lack of training).

CONCLUSIONS

This study identified a range of potential barriers and facilitators to the implementation of alcohol SBI delivery in primary care and adds to the scarce body of literature that identifies the barriers and facilitators from a theoretical perspective. Given that alcohol SBI is seldom implemented, this review provides researchers with a tool for designing novel theory-oriented interventions to support the implementation of such activity.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016052681.

A rapid pre-implementation evaluation to inform a family engagement navigator program during COVID-19

BACKGROUND

Innovative models of family engagement and support are needed in the intensive care unit (ICU) during times of restricted visitation such as the COVID-19 pandemic. Limited understanding of the factors affecting the uptake and outcomes of different family support models hinders the implementation of best practices. We aimed to conduct a rapid pre-implementation evaluation of stakeholder-perceived facilitators and barriers to design implementation strategies to support a novel program using medical students to facilitate family-centered care in the ICU.

METHODS

We conducted a 2-step process. In step 1, we gathered contextual data via interview-style open-ended questions sent to clinicians and navigator stakeholders via email. We used electronic data collection due to the physical distancing requirements, the need to prioritize brief data collection for respondent burden, and the need for rapid knowledge gain. A codebook based on the Consolidated Framework for Implementation Research (CFIR), an integrated framework from the field of implementation science, was used to analyze the findings. In step 2, a pilot of the intervention was implemented with 3 navigators over 2 weeks. Implementation strategies were developed to target barriers identified by the pre-implementation evaluation.

RESULTS

Fourteen (70%) of the identified stakeholders responded to the survey. Ten constructs encompassing all five CFIR domains were present in responses as implementation influencers, with the Intervention domain most frequently represented. Through these results and operational feedback from navigators during the pilot period, stakeholders selected multiple implementation strategies: audit and provide feedback, develop educational materials, conduct ongoing training, promote adaptability, assess and redesign workflow, identify and prepare champions, and engage community resources.

CONCLUSIONS

We demonstrated how a conceptually based pre-implementation program evaluation can be used to rapidly inform optimal implementation strategies. We report key factors to inform design and implementation strategies for a novel ICU family engagement navigator program that may be useful to others wishing to adopt similar programs.

Facilitators and Barriers to Implementing Standardized Outcome Measurement for Children With Cleft Lip and Palate

OBJECTIVE

Identify facilitators and barriers to implementing standardized outcome measurement in cleft care.

DESIGN

Cross-sectional, qualitative study.

SETTING/PARTICIPANTS

Participants included 24 providers and staff from a large, multidisciplinary cleft team in the southwest United States, 5 caregivers of children with cleft palate (with or without cleft lip) treated by this team, and 3 experts involved in implementing a cleft-specific standardized outcome measurement in the United Kingdom.

INTERVENTIONS

Semistructured, qualitative interviews were conducted exploring perceived facilitators and barriers to implementing standardized outcome measurement in cleft care. Interviews were audio-recorded, transcribed, and analyzed for content. The Consolidated Framework for Implementation Research was used to guide the interviews and analysis. The analysis focused on the characteristics of standardized outcome measurement that directly influence its adoption.

RESULTS

Participants identified both facilitators and barriers to implementing standardized outcome measurement. Facilitators included the strength and quality of evidence supporting improvements in cleft care delivery following implementation of standardized outcome measurement and the relative advantage of standardized outcome measurement over continuing the status quo. Barriers included the difficulty adapting standardized outcome measurement to meet local context and patient-specific needs and the complexity of implementing standardized outcome measurement.

CONCLUSIONS

Providers, staff, and caregivers involved in cleft care perceive multiple benefits from standardized outcome measurement, while also recognizing substantial barriers to its implementation. Results from this study can be used to guide development of an implementation strategy for standardized outcome measurement that builds upon perceived strengths of the intervention and reduces perceived barriers.

Applying an intersectionality lens to the theoretical domains framework: a tool for thinking about how intersecting social identities and structures of power influence behaviour

Background

A key component of the implementation process is identifying potential barriers and facilitators that need to be addressed. The Theoretical Domains Framework (TDF) is one of the most commonly used frameworks for this purpose. When applying the TDF, it is critical to understand the context in which behaviours occur. Intersectionality, which accounts for the interface between social identity factors (e.g. age, gender) and structures of power (e.g. ageism, sexism), offers a novel approach to understanding how context shapes individual decision-making and behaviour. We aimed to develop a tool to be used alongside applications of the TDF to incorporate an intersectionality lens when identifying implementation barriers and enablers.

Methods

An interdisciplinary Framework Committee (n = 17) prioritized the TDF as one of three models, theories, and frameworks (MTFs) to enhance with an intersectional lens through a modified Delphi approach. In collaboration with the wider Framework Committee, a subgroup considered all 14 TDF domains and iteratively developed recommendations for incorporating intersectionality considerations within the TDF and its domains. An iterative approach aimed at building consensus was used to finalize recommendations.

Results

Consensus on how to apply an intersectionality lens to the TDF was achieved after 12 rounds of revision. Two overarching considerations for using the intersectionality alongside the TDF were developed by the group as well as two to four prompts for each TDF domain to guide interview topic guides. Considerations and prompts were designed to assist users to reflect on how individual identities and structures of power may play a role in barriers and facilitators to behaviour change and subsequent intervention implementation.

Conclusions

Through an expert-consensus approach, we developed a tool for applying an intersectionality lens alongside the TDF. Considering the role of intersecting social factors when identifying barriers and facilitators to implementing research evidence may result in more targeted and effective interventions that better reflect the realities of those involved.

The disconnect between knowing and doing in health professions education and practice

Safe and effective healthcare requires that new knowledge or skills, once learned, are incorporated into professional practice. However, this process is not always straightforward. Learning takes place in complex contexts, requiring practitioners to overcome various motivational, systemic, emotional, and social barriers to the application of knowledge. This paper explores the mechanisms through which individuals translate knowledge into action to provide insight into why disconnects between knowledge and action can arise. As a critical review, the aim was to draw on key literature from multiple fields to analyse and synthesize existing schools of thought and lay a strong conceptual foundation on which knowledge to action gaps might be considered. We iteratively consulted clinicians and experts in various fields to guide literature searches focused on theoretical perspectives that could inform educational and research efforts around knowledge-to-action gaps. Key theoretical perspectives on motivation address when and how individuals decide to take action. Literatures from cognitive science address how clinicians and learners self-regulate to (sometimes) overcome barriers to action. Sociocultural theories examine the ways in which action might be prevented by social norms that conflict with what the individual knows and believes, potentially also giving rise to counter-normative action. No single perspective will entirely explain how health professionals and learners implement knowledge in practice. As a result, the authors offer multiple lenses through which to view the problem, and then propose how each of these lenses might better guide educational and research efforts to untangle this challenging but important issue.

Implementing guideline-checklists: Evaluating health care providers intentional behaviour using an extended model of the theory of planned behaviour

OBJECTIVES

Internationally, clinical guidelines as checklists are increasingly used in acute ward practice to standardize the delivery and raise the quality of care on acute hospital wards. However, when guideline-checklists are implemented repeatedly, health providers' intentions to carry out this type of behaviour are not well understood. Therefore, the objective of this study was to evaluate nurses' and health care assistants' (HCAs) intentions to implement a "care round checklist"; a guideline-intervention repeated hourly on hospital wards. Furthermore, an extended Theory of Planned Behaviour (TPB) model's usefulness in explaining this type of behaviour was also evaluated.

METHODS

A theory-informed questionnaire, guided by the TPB, habit, and clinical context variables, was developed to measure the guideline-checklist behaviour. Quantitative questionnaire data were analysed using descriptive and inferential tests to establish differences in nurses' and HCAs' intentions and the predictive value of the model.

RESULTS

A sample of 270 nurses and HCAs returned questionnaires from 24 wards in a major hospital in England. The extended TPB model explained 20% of nurses and 24% of HCAs reported intentions to implement a care round checklist, a modest proportion of intent. Attitude and perceived control best predicted nurses' intentions, and attitude and practice habit HCAs' intentions. TPB belief variables helped explain why nurses and HCAs intentions were different.

CONCLUSIONS

Statistically, the extended TPB model highlighted that nurses and HCAs intentions to implement this type of guideline are predicted by different variables. This implied professional "role" as an important variable in explaining differences in intentions, which should be evaluated and integrated into the future design of this type of checklist. Further variables could be added to explain and learn more about intentional thinking for this type of behaviour and should help to develop a theoretical understanding of intentions underpinning this type of behaviour and ultimately improve patient care.

Impact of an Opioid Safety Initiative on Patients Undergoing Total Knee Arthroplasty

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

The Opioid Safety Initiative decreased high-dose prescriptions across the Veterans Health Administration. This study sought to examine the impact of this intervention (i.e., the Opioid Safety Initiative) on pain scores and opioid prescriptions in patients undergoing total knee arthroplasty.

Methods

This was an ecological study of group-level data among 700 to 850 patients per month over 72 consecutive months (January 2010 to December 2015). The authors examined characteristics of cohorts treated before versus after rollout of the Opioid Safety Initiative (October 2013). Each month, the authors aggregated at the group-level the differences between mean postoperative and preoperative pain scores for each patient (averaged over 6-month periods), and measured proportions of patients (per 1,000) with opioid (and nonopioid) prescriptions for more than 3 months in 6-month periods, preoperatively and postoperatively. The authors compared postintervention trends versus trends forecasted based on preintervention measures.

Results

After the Opioid Safety Initiative, patients were slightly older and sicker, but had lower mortality rates (postintervention n = 28,509 vs. preintervention n = 31,547). Postoperative pain scores were slightly higher and the decrease in opioid use was statistically significant, i.e., 871 (95% CI, 474 to 1,268) fewer patients with chronic postoperative prescriptions. In time series analyses, mean postoperative minus preoperative pain scores had increased from 0.65 to 0.81, by 0.16 points (95% CI, 0.05 to 0.27). Proportions of patients with chronic postoperative and chronic preoperative opioid prescriptions had declined by 20% (n = 3,355 vs. expected n = 4,226) and by 13% (n = 5,861 vs. expected n = 6,724), respectively. Nonopioid analgesia had increased. Sensitivity analyses confirmed all findings.

Conclusions

A system-wide initiative combining guideline dissemination with audit and feedback was effective in significantly decreasing opioid prescriptions in populations undergoing total knee arthroplasty, while minimally impacting pain scores.

How does feedback shared with interprofessional health care teams shape nursing performance improvement systems? A rapid realist review protocol

BACKGROUND

Nursing care quality varies between hospitals, and even between departments within the same institution. Suboptimal care can have deleterious consequences for patients such as lengthened hospital stay, nosocomial infection, pressure ulcers or death. Experts recommend the implementation of nursing performance improvement systems to assess team performance and monitor patient outcomes and efficiency savings. In practice, these systems are expected to include feedback processes directed towards nursing teams and interprofessional staff in order to facilitate adjustments and improve their performance. Unfortunately, feedback appears somewhat haphazard and, at times, overlooked. This could be explained by an ongoing absence of clear recommendations. As a result, feedback effects are inconclusive: some teams improve their practice, others do not. Although feedback has been conceptualised and studied from different theoretical perspectives, ongoing empirical inconsistencies remain unexplained. The goal of this rapid realist review protocol is to develop a theory that explains how feedback shared with interprofessional health care teams shape nursing performance improvement systems.

METHOD

This study follows standard guidelines established for realist reviews. Mechanisms at work will be analysed using Actor-Network Theory. All scientific documents are selected from five databases, are published in both English and French between 2010 and 2018, and include empirical research, reviews and grey literature. First, selection of documents will proceed on the basis of titles and abstracts; followed by a second selection by reading the remaining full texts. Inclusion criteria and a data extraction form will be pilot tested with 40 articles prior to completion by two reviewers. Data will be summarised in the form of [context, mechanism, outcome] equations to theorise operational feedback.

DISCUSSION

The innovative combination of Actor-Network Theory with a realist methodology holds promise for the identification of explanatory equations in complex systems and theory development. A rapid realist review is relevant to address an enduring knowledge gap which requires theory development. This preliminary study lays the groundwork for a pioneering theory on feedback in nursing performance improvement systems that will subsequently inform a multiple case study.

SYSTEMATIC REVIEW REGISTRATION

Prospero CRD42018110128.

Clinical Performance Feedback Intervention Theory (CP-FIT): a new theory for designing, implementing, and evaluating feedback in health care based on a systematic review and meta-synthesis of qualitative research

BACKGROUND

Providing health professionals with quantitative summaries of their clinical performance when treating specific groups of patients ("feedback") is a widely used quality improvement strategy, yet systematic reviews show it has varying success. Theory could help explain what factors influence feedback success, and guide approaches to enhance effectiveness. However, existing theories lack comprehensiveness and specificity to health care. To address this problem, we conducted the first systematic review and synthesis of qualitative evaluations of feedback interventions, using findings to develop a comprehensive new health care-specific feedback theory.

METHODS

We searched MEDLINE, EMBASE, CINAHL, Web of Science, and Google Scholar from inception until 2016 inclusive. Data were synthesised by coding individual papers, building on pre-existing theories to formulate hypotheses, iteratively testing and improving hypotheses, assessing confidence in hypotheses using the GRADE-CERQual method, and summarising high-confidence hypotheses into a set of propositions.

RESULTS

We synthesised 65 papers evaluating 73 feedback interventions from countries spanning five continents. From our synthesis we developed Clinical Performance Feedback Intervention Theory (CP-FIT), which builds on 30 pre-existing theories and has 42 high-confidence hypotheses. CP-FIT states that effective feedback works in a cycle of sequential processes; it becomes less effective if any individual process fails, thus halting progress round the cycle. Feedback's success is influenced by several factors operating via a set of common explanatory mechanisms: the feedback method used, health professional receiving feedback, and context in which feedback takes place. CP-FIT summarises these effects in three propositions: (1) health care professionals and organisations have a finite capacity to engage with feedback, (2) these parties have strong beliefs regarding how patient care should be provided that influence their interactions with feedback, and (3) feedback that directly supports clinical behaviours is most effective.

CONCLUSIONS

This is the first qualitative meta-synthesis of feedback interventions, and the first comprehensive theory of feedback designed specifically for health care. Our findings contribute new knowledge about how feedback works and factors that influence its effectiveness. Internationally, practitioners, researchers, and policy-makers can use CP-FIT to design, implement, and evaluate feedback. Doing so could improve care for large numbers of patients, reduce opportunity costs, and improve returns on financial investments.

TRIAL REGISTRATION

PROSPERO, CRD42015017541.

Clinical performance comparators in audit and feedback: a review of theory and evidence

BACKGROUND

Audit and feedback (A&F) is a common quality improvement strategy with highly variable effects on patient care. It is unclear how A&F effectiveness can be maximised. Since the core mechanism of action of A&F depends on drawing attention to a discrepancy between actual and desired performance, we aimed to understand current and best practices in the choice of performance comparator.

METHODS

We described current choices for performance comparators by conducting a secondary review of randomised trials of A&F interventions and identifying the associated mechanisms that might have implications for effective A&F by reviewing theories and empirical studies from a recent qualitative evidence synthesis.

RESULTS

We found across 146 trials that feedback recipients' performance was most frequently compared against the performance of others (benchmarks; 60.3%). Other comparators included recipients' own performance over time (trends; 9.6%) and target standards (explicit targets; 11.0%), and 13% of trials used a combination of these options. In studies featuring benchmarks, 42% compared against mean performance. Eight (5.5%) trials provided a rationale for using a specific comparator. We distilled mechanisms of each comparator from 12 behavioural theories, 5 randomised trials, and 42 qualitative A&F studies.

CONCLUSION

Clinical performance comparators in published literature were poorly informed by theory and did not explicitly account for mechanisms reported in qualitative studies. Based on our review, we argue that there is considerable opportunity to improve the design of performance comparators by (1) providing tailored comparisons rather than benchmarking everyone against the mean, (2) limiting the amount of comparators being displayed while providing more comparative information upon request to balance the feedback's credibility and actionability, (3) providing performance trends but not trends alone, and (4) encouraging feedback recipients to set personal, explicit targets guided by relevant information.

How the study of networks informs knowledge translation and implementation: a scoping review

Background

To date, implementation science has focused largely on identifying the individual and organizational barriers, processes, and outcomes of knowledge translation (KT) (including implementation efforts). Social network analysis (SNA) has the potential to augment our understanding of KT success by applying a network lens that examines the influence of relationships and social structures on research use and intervention acceptability by health professionals. The purpose of this review was to comprehensively map the ways in which SNA methodologies have been applied to the study of KT with respect to health professional networks.

Methods

Systematic scoping review methodology involved searching five academic databases for primary research on KT that employed quantitative SNA methods, and inclusion screening using predetermined criteria. Data extraction included information on study aim, population, variables, network properties, theory use, and data collection methods. Descriptive statistics and chronology charting preceded theoretical analysis of findings.

Results

Twenty-seven retained articles describing 19 cross-sectional and 2 longitudinal studies reported on 28 structural properties, with degree centrality, tie characteristics (e.g., homophily, reciprocity), and whole network density being most frequent. Eleven studies examined physician-only networks, 9 focused on interprofessional networks, and 1 reported on a nurse practitioner network. Diffusion of innovation, social contagion, and social influence theories were most commonly applied.

Conclusions

Emerging interest in SNA for KT- and implementation-related research is evident. The included articles focused on individual level evidence-based decision-making: we recommend also applying SNA to meso- or macro-level KT activities. SNA research that expands the range of professions under study, examines network dynamics over time, extends the depth of analysis of the role of network structure on KT processes and outcomes, and employs mixed methods to triangulate findings, is needed to advance the field. SNA is a valuable approach for evaluating key network characteristics, structures and positions of relevance to KT, implementation, and evidence informed practice. Examining how network structure influences connections and the implications of those holding prominent network positions can provide insights to improve network-based KT processes.

Implementing alcohol screening and brief interventions in primary health care: study protocol for a pilot cluster randomized controlled trial

BACKGROUND

Alcohol is one of the most important risk factors contributing to the global burden of disease. Screening and brief interventions in primary care settings are effective in reducing alcohol consumption. However, implementation of such interventions in routine practice has been proven difficult. Most programmes in practice and research have lacked a theoretical rationale for how they would change practitioner behaviour.

OBJECTIVE

To determine whether a theory-based behaviour change intervention delivered to primary care practices significantly increases delivery of alcohol screening.

METHODS

We will conduct a two-arm, cluster-randomized controlled, parallel, open trial. Twelve primary care practices will be randomized to one of two groups: training and support; and waiting-list control. Family physicians, nurses and receptionists will be eligible to participate. The intervention will be a training and support programme. The intervention will be tailored to the barriers and facilitators for implementing alcohol screening and brief interventions following the principles of the Behaviour Change Wheel approach. The primary outcome will be the proportion of patients screened with the Alcohol Use Disorders Identification Test.

CONCLUSION

This study will test whether a theory-driven implementation programme increases alcohol screening rates in primary care. Results from this trial will provide a useful addition to existing evidence by informing implementation researchers what areas of behaviour change are critical to increasing alcohol screening rates.

TRIAL REGISTRATION

clinicaltrials.gov NCT02968186.

Audit and feedback in mental healthcare: staff experiences

Purpose

Audit and feedback (A&F) often underlie implementation projects, described as a circular process; i.e. an A&F cycle. They are widely used, but effect varies with no apparent explanation. We need to understand how A&F work in real-life situations. The purpose of this paper, therefore, is to describe and explore mental healthcare full A&F cycle experiences.

Design/methodology/approach

This is a naturalistic qualitative study that uses four focus groups and qualitative content analysis.

Findings

Staff accepted the initial A&F stages, perceiving it to enhance awareness and reassure them about good practice. They were willing to participate in the full cycle and implement changes, but experienced poor follow-up and prioritization, not giving them a chance to own to the process. An important finding is the need for an A&F cycle facilitator.

Practical implications

Research teams cannot be expected to be involved in implementing clinical care. Guidelines will keep being produced to improve service quality and will be expected to be practiced. This study gives insights into planning and tailoring A&F cycles.

Originality/value

Tools to ease implementation are not enough, and the key seems to lie with facilitating a process using A&F. This study underscores leadership, designated responsibility and facilitation throughout a full audit cycle.

Development and usability testing of an audit and feedback tool for anesthesiologists

Background

We describe the creation and evaluation of a personal audit and feedback (A&F) tool for anesthesiologists.

Methods

A survey aimed at capturing barriers for personal improvement efforts and feedback preferences was administered to attending anesthesiologists. The results informed the design and implementation of 4 dashboards that display information on individual practice characteristics as well as comparative performance on several quality metrics. The dashboards’ usability was then tested using the human-centered design framework.

Results

Anesthesiologists listed lack of information on current practice as the main barrier for improvement. Regarding usability, participants gave the dashboards an average score of 3.8 (scale 1–5) on consistency, learnability, and information organization, and performed the assigned tasks well, with an average score of 89% (range 79–100%).

Conclusions

We describe the design, implementation, and usability testing of an innovative tool that utilizes data derived from the electronic health record (EHR) system to provide A&F to anesthesiology providers.

Impact of Self- and Peer Assessment on the Clinical Performance of Physiotherapists in Primary Care: A Cohort Study

Purpose: This study evaluated the impact of a quality improvement programme based on self- and peer assessment to justify nationwide implementation. Method: Four professional networks of physiotherapists in The Netherlands (n = 379) participated in the programme, which consisted of two cycles of online self-assessment and peer assessment using video recordings of client communication and clinical records. Assessment was based on performance indicators that could be scored on a 5-point Likert scale, and online assessment was followed by face-to-face feedback discussions. After cycle 1, participants developed personal learning goals. These goals were analyzed thematically, and goal attainment was measured using a questionnaire. Improvement in performance was tested with multilevel regression analyses, comparing the self-assessment and peer-assessment scores in cycles 1 and 2. Results: In total, 364 (96%) of the participants were active in online self-assessment and peer assessment. However, online activities varied between cycle 1 and cycle 2 and between client communication and recordkeeping. Personal goals addressed client-centred communication (54%), recordkeeping (24%), performance and outcome measurement (15%), and other (7%). Goals were completely attained (29%), partly attained (64%), or not attained at all (7%). Self-assessment and peer-assessment scores improved significantly for both client communication (self-assessment = 11%; peer assessment = 8%) and recordkeeping (self-assessment = 7%; peer assessment = 4%). Conclusions: Self-assessment and peer assessment are effective in enhancing commitment to change and improving clinical performance. Nationwide implementation of the programme is justified. Future studies should address the impact on client outcomes.

Knowledge translation for realist reviews: a participatory approach for a review on scaling up complex interventions

Background

Knowledge syntheses that use a realist methodology are gaining popularity. Yet, there are few reports in the literature that describe how results are summarised, shared and used. This paper aims to inform knowledge translation (KT) for realist reviews by describing the process of developing a KT strategy for a review on pathways for scaling up complex public health interventions.

Methods

The participatory approach used for the realist review was also used to develop the KT strategy. The approach included three main steps, namely (1) an international meeting focused on interpreting preliminary findings from the realist review and seeking input on KT activities; (2) a targeted literature review on KT for realist reviews; and (3) consultations with primary knowledge users of the review.

Results

The international meeting identified a general preference among knowledge users for findings from the review that are action oriented. A need was also identified for understanding how to tailor findings for specific knowledge user groups in relation to their needs. The literature review identified four papers that included brief descriptions of planned or actual KT activities for specific research studies; however, information was minimal on what KT activities or products work for whom, under what conditions and why. The consultations revealed that KT for realist reviews should consider the following: (1) activities closely aligned with the preferences of specific knowledge user groups; (2) key findings that are sensitive to factors within the knowledge user’s context; and (3) actionable statements that can advance KT goals, activities or products. The KT strategy derived from the three activities includes a planning framework and tailored KT activities that address preferences of knowledge users for findings that are action oriented and context relevant.

Conclusions

This paper provides an example of a KT strategy for realist reviews that blends theoretical and practical insights. Evaluation of the strategy’s implementation will provide useful insights on its effectiveness and potential for broader application.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0374-1) contains supplementary material, which is available to authorized users.

SMASH! The Salford medication safety dashboard

BACKGROUND

Patient safety is vital to well-functioning health systems. A key component is safe prescribing, particularly in primary care where most medications are prescribed. Previous research demonstrated that the number of patients exposed to potentially hazardous prescribing can be reduced by interrogating the electronic health record (EHR) database of general practices and providing feedback to general practitioners in a pharmacist-led intervention. We aimed to develop and roll out an online dashboard application that delivers this audit and feedback intervention in a continuous fashion.

METHOD

Based on initial system requirements we designed the dashboard's user interface over 3 iterations with 6 general practitioners (GPs), 7 pharmacists and a member of the public. Prescribing safety indicators from previous work were implemented in the dashboard. Pharmacists were trained to use the intervention and deliver it to general practices.

RESULTS

A web-based electronic dashboard was developed and linked to shared care records in Salford, UK. The completed dashboard was deployed in all but one (n=43) general practices in the region. By November 2017, 36 pharmacists had been trained in delivering the intervention to practices. There were 135 registered users of the dashboard, with an average of 91 user sessions a week.

CONCLUSION

We have developed and successfully rolled out of a complex, pharmacist-led dashboard intervention in Salford, UK. System usage statistics indicate broad and sustained uptake of the intervention. The use of systems that provide regularly updated audit information may be an important contributor towards medication safety in primary care.

Developing a valid and reliable assessment of knowledge translation (KT) for continuing professional development program of health professionals

Introduction

Knowledge Translation (KT) is expected to be a critical learning outcome of a Continuing Professional Development (CPD) program. It continues to serve as an area of interest among educators and healthcare providers due to its importance to evidence-based practice. This study endeavored to develop a valid and reliable KT learning assessment tool in CPD.

Methods

The Inventory of Reflective Vignettes (IRV), an innovative approach of integrating research vignettes, was utilized in crafting the 20-item IRV-KT tool. This instrument includes knowledge creation and action as essential KT constructs. KT competency was assessed in three segments (i.e., before and after CPD event and if in a lecture) using a one-group post-posttest pre-experimental design. Health professionals who successfully completed a CPD program on a knowledge translation topic were asked to complete the IRV-KT during the pilot study (n = 10) and actual implementation (n = 45). Responses were subjected to Cronbach’s reliability and criterion-validity testing.

Results

The initial test of the IRV-KT tool demonstrated a high internal reliability (α = 0.97) and most items yielded acceptable validity scores. During the actual implementation, a higher reliability score of 0.98 was generated with significant correlations between the before-after segments for both KT constructs of creation (r = 0.33, p < 0.05) and action (r = 0.49, p < 0.05). All items have significant positive validity coefficients (r > 0.35, p < 0.05) in all segments of the tool.

Discussion

The study produced a reflective assessment tool to validly and reliably assess KT learning in a CPD. IRV-KT is seen to guide the curriculum process of CPD programs to bridge learning and healthcare outcomes.

Evaluating broad-scale system change using the Consolidated Framework for Implementation Research: challenges and strategies to overcome them

OBJECTIVE

The objective of this paper is to demonstrate the utility of the CFIR framework for evaluating broad-scale change by discussing the challenges to be addressed when planning the assessment of broad-scale change and the solutions developed by the evaluation team to address those challenges. The evaluation of implementation of Patient-centered Care and Cultural Transformation (PCC&CT) within the Department of Veterans Affairs (VA) will be used as a demonstrative example. Patient-Centered Care (PCC) is personalized health care that considers a patient's circumstances and goals. The Department of Veterans Affairs (VA) is working towards implementing PCC throughout its healthcare system, comprised of multiple interventions with a singular long-term goal of cultural transformation, however little is known about the factors influencing its implementation. This paper discusses the issues that arose using CFIR to qualitatively assess the factors influencing implementation of cultural transformation.

RESULTS

Application of CFIR to this broad-scale evaluation revealed three strategies recommended for use in evaluating implementation of broad-scale change: (1) the need for adapted definitions for CFIR constructs (especially due to new application to broad-scale change), (2) the use of a mixed deductive-inductive approach with thematic coding to capture emergent themes not encompassed by CFIR, and (3) its use for expedited analysis and synthesis for rapid delivery of findings to operational partners. This paper is among the first to describe use of CFIR to guide the evaluation of a broad-scale transformation, as opposed to discrete interventions. The processes and strategies described in this paper provide a detailed example and structured approach that can be utilized and expanded upon by others evaluating implementation of broad-scale evaluations. Although CFIR was the framework selected for this evaluation, the strategies described in this paper including: use of adapted definitions, use of mixed deductive-inductive approach, and the approach for expedited analysis and synthesis can be transferred and tested with other frameworks.

Effect of a population-level performance dashboard intervention on maternal-newborn outcomes: an interrupted time series study

OBJECTIVES

To assess the effect of the Maternal Newborn Dashboard on six key clinical performance indicators in the province of Ontario, Canada.

DESIGN

Interrupted time series using population-based data from the provincial birth registry covering a 3-year period before implementation of the Dashboard and 2.5 years after implementation (November 2009 through March 2015).

SETTING

All hospitals in the province of Ontario providing maternal-newborn care (n=94).

INTERVENTION

A hospital-based online audit and feedback programme.

MAIN OUTCOME MEASURES

Rates of the six performance indicators included in the Dashboard.

RESULTS

2.5 years after implementation, the audit and feedback programme was associated with statistically significant absolute decreases in the rates of episiotomy (decrease of 1.5 per 100 women, 95% CI 0.64 to 2.39), induction for postdates in women who were less than 41 weeks at delivery (decrease of 11.7 per 100 women, 95% CI 7.4 to 16.0), repeat caesarean delivery in low-risk women performed before 39 weeks (decrease of 10.4 per 100 women, 95% CI 9.3 to 11.5) and an absolute increase in the rate of appropriately timed group B streptococcus screening (increase of 2.8 per 100, 95% CI 2.2 to 3.5). The audit and feedback programme did not significantly affect the rates of unsatisfactory newborn screening blood samples or formula supplementation at discharge. No statistically significant effects were observed for the two internal control outcomes or the four external control indicators-in fact, two external control indicators (episiotomy and postdates induction) worsened relative to before implementation.

CONCLUSION

An electronic audit and feedback programme implemented in maternal-newborn hospitals was associated with clinically relevant practice improvements at the provincial level in the majority of targeted indicators.

Scoping review identifies significant number of knowledge translation theories, models, and frameworks with limited use

OBJECTIVES

To conduct a scoping review of knowledge translation (KT) theories, models, and frameworks that have been used to guide dissemination or implementation of evidence-based interventions targeted to prevention and/or management of cancer or other chronic diseases.

STUDY DESIGN AND SETTING

We used a comprehensive multistage search process from 2000 to 2016, which included traditional bibliographic database searching, searching using names of theories, models and frameworks, and cited reference searching. Two reviewers independently screened the literature and abstracted the data.

RESULTS

We found 596 studies reporting on the use of 159 KT theories, models, or frameworks. A majority (87%) of the identified theories, models, or frameworks were used in five or fewer studies, with 60% used once. The theories, models, and frameworks were most commonly used to inform planning/design, implementation and evaluation activities, and least commonly used to inform dissemination and sustainability/scalability activities. Twenty-six were used across the full implementation spectrum (from planning/design to sustainability/scalability) either within or across studies. All were used for at least individual-level behavior change, whereas 48% were used for organization-level, 33% for community-level, and 17% for system-level change.

CONCLUSION

We found a significant number of KT theories, models, and frameworks with a limited evidence base describing their use.

The Professional Culture of Community Pharmacy and the Provision of MTM Services

The integration of advanced pharmacy services into community pharmacy practice is not complete. According to implementation research understanding professional culture, as a part of context, may provide insights for accelerating this process. There are three objectives in this study. The first objective of this study was to validate an adapted version of an organizational culture measure in a sample of United States' (US) community pharmacists. The second objective was to examine potential relationships between the cultural factors identified using the validated instrument and a number of socialization and education variables. The third objective was to examine any relationships between the scores on the identified cultural factors and the provision of MTM services. This study was a cross-sectional online survey for community pharmacists in the southeastern US. The survey contained questions on socialization/education, respondents' self-reported provision of medication therapy management (MTM) services, and the organizational culture profile (OCP). Analyses included descriptive statistics, a principle components analysis (PCA), independent samples t-test, and multivariate ordinal regression. A total of 303 surveys were completed. The PCA revealed a six-factor structure: social responsibility, innovation, people orientation, competitiveness, attention to detail, and reward orientation. Further analysis revealed significant relationships between social responsibility and years in practice, and people orientation and attention to detail and pharmacists' training and practice setting. Significant positive relationships were observed between social responsibility, innovation, and competitiveness and the increased provision of MTM services. The significant relationships identified between the OCP factors and community pharmacist respondents' provision of MTM services provides an important starting point for developing interventions to improve the uptake of practice change opportunities.

Classification schemes for knowledge translation interventions: a practical resource for researchers

BACKGROUND

As implementation science advances, the number of interventions to promote the translation of evidence into healthcare, health systems, or health policy is growing. Accordingly, classification schemes for these knowledge translation (KT) interventions have emerged. A recent scoping review identified 51 classification schemes of KT interventions to integrate evidence into healthcare practice; however, the review did not evaluate the quality of the classification schemes or provide detailed information to assist researchers in selecting a scheme for their context and purpose. This study aimed to further examine and assess the quality of these classification schemes of KT interventions, and provide information to aid researchers when selecting a classification scheme.

METHODS

We abstracted the following information from each of the original 51 classification scheme articles: authors' objectives; purpose of the scheme and field of application; socioecologic level (individual, organizational, community, system); adaptability (broad versus specific); target group (patients, providers, policy-makers), intent (policy, education, practice), and purpose (dissemination versus implementation). Two reviewers independently evaluated the methodological quality of the development of each classification scheme using an adapted version of the AGREE II tool. Based on these assessments, two independent reviewers reached consensus about whether to recommend each scheme for researcher use, or not.

RESULTS

Of the 51 original classification schemes, we excluded seven that were not specific classification schemes, not accessible or duplicates. Of the remaining 44 classification schemes, nine were not recommended. Of the 35 recommended classification schemes, ten focused on behaviour change and six focused on population health. Many schemes (n = 29) addressed practice considerations. Fewer schemes addressed educational or policy objectives. Twenty-five classification schemes had broad applicability, six were specific, and four had elements of both. Twenty-three schemes targeted health providers, nine targeted both patients and providers and one targeted policy-makers. Most classification schemes were intended for implementation rather than dissemination.

CONCLUSIONS

Thirty-five classification schemes of KT interventions were developed and reported with sufficient rigour to be recommended for use by researchers interested in KT in healthcare. Our additional categorization and quality analysis will aid in selecting suitable classification schemes for research initiatives in the field of implementation science.

Towards an understanding of how appraisal of doctors produces its effects: a realist review

CONTEXT

Revalidation was launched in the UK to provide assurances to the public that doctors are up to date and fit to practice. Appraisal is a fundamental component of revalidation. Approximately 150 000 doctors are appraised annually, costing an estimated £97 million over 10 years. There is little understanding of the theory of how and why appraisal is supposed to produce its effects. A realist review of the literature was utilised to explore these issues, as they generate context-mechanism-outcome (CMO) configurations, resulting in the creation of theories of how and why appraisal of doctors produces its effects.

METHODS

A programme theory of appraisal was created by convening stakeholders in appraisal and searching a database of research on appraisal of doctors. Supplementary searches provided literature on theories identified in the programme theory. Relevant sections of texts relating to the programme theory were extracted from included articles, coded in NVivo and synthesised using realist logic of analysis. A classification tool categorised the included articles' contributions to programme theory.

RESULTS

One hundred and twenty-five articles were included. Three mechanisms were identified: dissonance, denial and self-affirmation. The dissonance mechanism is most likely to cause outcomes of reflection and insight. Important contexts for the dissonance mechanism include the appraiser being highly skilled, the appraisee's working environment being supportive and the appraisee having the right attitude. The denial mechanism is more likely to be enacted if the opposite of these contexts occurs and could lead to game-playing behaviour. A skilled appraiser was also important in triggering the self-affirmation mechanism, resulting in reflection and insight. The contexts, mechanisms and outcomes identified were, however, limited by a lack of evidence that could enable further refining of the CMO configurations.

CONCLUSION

This review makes a significant contribution to our understanding of appraisal by identifying different ways that appraisal of doctors produces its effects. Further research will focus on testing the CMO configurations.

Advancing the literature on designing audit and feedback interventions: identifying theory-informed hypotheses

BACKGROUND

Audit and feedback (A&F) is a common strategy for helping health providers to implement evidence into practice. Despite being extensively studied, health care A&F interventions remain variably effective, with overall effect sizes that have not improved since 2003. Contributing to this stagnation is the fact that most health care A&F interventions have largely been designed without being informed by theoretical understanding from the behavioral and social sciences. To determine if the trend can be improved, the objective of this study was to develop a list of testable, theory-informed hypotheses about how to design more effective A&F interventions.

METHODS

Using purposive sampling, semi-structured 60-90-min telephone interviews were conducted with experts in theories related to A&F from a range of fields (e.g., cognitive, health and organizational psychology, medical decision-making, economics). Guided by detailed descriptions of A&F interventions from the health care literature, interviewees described how they would approach the problem of designing improved A&F interventions. Specific, theory-informed hypotheses about the conditions for effective design and delivery of A&F interventions were elicited from the interviews. The resulting hypotheses were assigned by three coders working independently into themes, and categories of themes, in an iterative process.

RESULTS

We conducted 28 interviews and identified 313 theory-informed hypotheses, which were placed into 30 themes. The 30 themes included hypotheses related to the following five categories: A&F recipient (seven themes), content of the A&F (ten themes), process of delivery of the A&F (six themes), behavior that was the focus of the A&F (three themes), and other (four themes).

CONCLUSIONS

We have identified a set of testable, theory-informed hypotheses from a broad range of behavioral and social science that suggest conditions for more effective A&F interventions. This work demonstrates the breadth of perspectives about A&F from non-healthcare-specific disciplines in a way that yields testable hypotheses for healthcare A&F interventions. These results will serve as the foundation for further work seeking to set research priorities among the A&F research community.

Implementation of internet-delivered cognitive behavior therapy within community mental health clinics: a process evaluation using the consolidated framework for implementation research

BACKGROUND

Depression and anxiety are prevalent and under treated conditions that create enormous burden for the patient and the health system. Internet-delivered cognitive behavior therapy (ICBT) improves patient access to treatment by providing therapeutic information via the Internet, presented in sequential lessons, accompanied by brief weekly therapist support. While there is growing research supporting ICBT, use of ICBT within community mental health clinics is limited. In a recent trial, an external unit specializing in ICBT facilitated use of ICBT in community mental health clinics in one Canadian province (ISRCTN42729166; registered November 5, 2013). Patient outcomes were very promising and uptake was encouraging. This paper reports on a parallel process evaluation designed to understand facilitators and barriers impacting the uptake and implementation of ICBT.

METHODS

Therapists (n = 22) and managers (n = 11) from seven community mental health clinics dispersed across one Canadian province who were involved in implementing ICBT over ~2 years completed an online survey (including open and closed-ended questions) about ICBT experiences. The questions were based on the Consolidated Framework for Implementation Research (CFIR), which outlines diverse constructs that have the potential to impact program implementation.

RESULTS

Analyses suggested ICBT implementation was perceived to be most prominently facilitated by intervention characteristics (namely the relative advantages of ICBT compared to face-to-face therapy, the quality of the ICBT program that was delivered, and evidence supporting ICBT) and implementation processes (namely the use of an external facilitation unit that aided with engaging patients, therapists, and managers and ICBT implementation). The inner setting was identified as the most significant barrier to implementation as a result of limited resources for ICBT combined with greater priority given to face-to-face care.

CONCLUSIONS

The results contribute to understanding facilitators and barriers to using ICBT within community mental health clinics and serve to identify recommendations for improving uptake and implementation of ICBT in clinic settings.

Toward an Information Infrastructure for Global Health Improvement

Profound global challenges to individual and population health, alongside the opportunities to benefit from digital technology, have spawned the concept of the Learning Health System. Learning Health Systems (LHSs)--which can function at organizational, network, regional, and national levels of scale--have the capability of continuous data-driven self-study that promotes change and improvement. The LHS concept, which originated in the U.S. in 2007, is rapidly gaining attention around the world. LHSs require, but also transcend, the secondary use of health data. This paper describes the key features of LHSs, argues that effective and sustainable LHSs must be supported by infrastructures that allow them to function with economies of scale and scope, and describes the services that such infrastructures must provide. While it is relatively straightforward to describe LHSs, achieving them at the high level of capability necessary to promote significant health benefits will require advancements in science and engineering, engaging the field of informatics among a wider range of disciplines. It also follows from this vision that LHSs cannot be built from an imposed blueprint; LHSs will more likely evolve from efforts at smaller scales that compose into larger systems.