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Getting evidence into practice: The role and function of facilitation
Abstract
Getting evidence into practice: the role and function of facilitation
Aim of paper. This paper presents the findings of a concept analysis of facilitation in relation to successful implementation of evidence into practice.
Background. In 1998, we presented a conceptual framework that represented the interplay and interdependence of the many factors influencing the uptake of evidence into practice. One of the three elements of the framework was facilitation, alongside the nature of evidence and context. It was proposed that facilitators had a key role in helping individuals and teams understand what they needed to change and how they needed to change it. As part of the on-going development and refinement of the framework, the elements within it have undergone a concept analysis in order to provide theoretical and conceptual clarity.
Methods. The concept analysis approach was used as a framework to review critically the research literature and seminal texts in order to establish the conceptual clarity and maturity of facilitation in relation to its role in the implementation of evidence-based practice.
Findings. The concept of facilitation is partially developed and in need of delineation and comparison. Here, the purpose, role and skills and attributes of facilitators are explored in order to try and make distinctions between this role and other change agent roles such as educational outreach workers, academic detailers and opinion leaders.
Conclusions. We propose that facilitation can be represented as a set of continua, with the purpose of facilitation ranging from a discrete task-focused activity to a more holistic process of enabling individuals, teams and organizations to change. A number of defining characteristics of facilitation are proposed. However, further research to clarify and evaluate different models of facilitation is required.
... Scholars propose a "facilitation continuum. " On one end of the continuum, the purpose of facilitation, and thus the role of the facilitator, is task-focused, e.g., to implement an evidence-based practice or program [33,34]. On the other end of the continuum, the purpose of facilitation, and thus the role of the facilitator, is holistic, e.g., to develop and empower individuals and teams and create a supportive context for change [29,33,35,36]. ...
... " On one end of the continuum, the purpose of facilitation, and thus the role of the facilitator, is task-focused, e.g., to implement an evidence-based practice or program [33,34]. On the other end of the continuum, the purpose of facilitation, and thus the role of the facilitator, is holistic, e.g., to develop and empower individuals and teams and create a supportive context for change [29,33,35,36]. The intended role of a facilitator can lie anywhere along this continuum. ...
... This study was part of a large project that successfully tested a facilitation strategy within the context of a Department of Veterans Affairs (VA) national initiative to implement evidence-based PCMHI care models [38]. The facilitation strategy was informed by the original Promoting Action on Implementation Research in Health Services (PARIHS) framework [33,39]. The project utilized a two-person facilitation team consisting of an expert external facilitator (EF) and an internal regional facilitator (IRF). ...
Background
Healthcare organizations have increasingly utilized facilitation to improve implementation of evidence-based practices and programs (e.g., primary care mental health integration). Facilitation is both a role, related to the purpose of facilitation, and a process, i.e., how a facilitator operationalizes the role. Scholars continue to call for a better understanding of this implementation strategy. Although facilitation is described as dynamic, activities are often framed within the context of a staged process. We explored two understudied characteristics of implementation facilitation: 1) how facilitation activities change over time and in response to context, and 2) how facilitators operationalize their role when the purpose of facilitation is both task-focused (i.e., to support implementation) and holistic (i.e., to build capacity for future implementation efforts).
Methods
We conducted individual monthly debriefings over thirty months with facilitators who were supporting PCMHI implementation in two VA networks. We developed a list of facilitation activities based on a literature review and debriefing notes and conducted a content analysis of debriefing notes by coding what activities occurred and their intensity by quarter. We also coded whether facilitators were “doing” these activities for sites or “enabling” sites to perform them.
Results
Implementation facilitation activities did not occur according to a defined series of ordered steps but in response to specific organizational contexts through a non-linear and incremental process. Amount and types of activities varied between the networks. Concordant with facilitators’ planned role, the focus of some facilitation activities was primarily on doing them for the sites and others on enabling sites to do for themselves; a number of activities did not fit into one category and varied across networks.
Conclusions
Findings indicate that facilitation is a dynamic and fluid process, with facilitation activities, as well as their timing and intensity, occurring in response to specific organizational contexts. Understanding this process can help those planning and applying implementation facilitation to make conscious choices about the facilitation role and the activities that facilitators can use to operationalize this role. Additionally, this work provides the foundation from which future studies can identify potential mechanisms of action through which facilitation activities enhance implementation uptake.
... In the beginning of 2000s, the concept of facilitation and the pivotal role that facilitators played in various contexts were subject to inconsistent conceptualizations and operationalizations (Harvey et al., 2002;Thompson et al., 2006). The efficacy of facilitation processes has been explored by various scholars, exemplified by Kitson, Harvey, and McCormack's framework for enabling evidence-based practice implementation (Kitson et al., 1998), as well as Meyer and Goes' contextual analysis of organizational assimilation of innovations (Meyer & Goes, 1998). ...
... The efficacy of facilitation processes has been explored by various scholars, exemplified by Kitson, Harvey, and McCormack's framework for enabling evidence-based practice implementation (Kitson et al., 1998), as well as Meyer and Goes' contextual analysis of organizational assimilation of innovations (Meyer & Goes, 1998). Facilitation purpose moves from "a discrete task-focused activity to a more holistic process of enabling individuals, teams and organisations to change" (Harvey et al., 2002). ...
Purpose. This viewpoint paper explores the practice of change facilitation, aiming to unveil how societies can nurture resilience in the face of imminent challenges. It synthesizes Ukrainian real-life experiences, revealing the principles behind various facilitation approaches to fostering resilient change in demanding contexts. Methodology. The study's methodology entails the synthesis and conceptualization of diverse professional experiences in Ukrainian realia, unravelling the underlying ethos behind various change facilitation approaches. By integrating these insights into broader perspectives and communities of practice, the research aims to offer a holistic perspective on fostering resilient change. Findings. The results section succinctly presents the distilled findings, offering a thought-provoking array of ideas specifically tailored for facilitators operating within high-stakes and extreme-risk and existential environments. Limitations/Implications. Due to the research approach, findings may lack generalizability, necessitating further testing of the presented propositions. Practical Implications. The study concludes by highlighting the potential impact of its professional interpretations on the fields of facilitation and social cohesion. The paper's content encompasses an exploration of facilitation, encompassing Ethos, Logos, and Pathos elements. It highlights the multifaceted role of a facilitator and presents three distinct approaches to implementing change: the knowledge and experience-driven approach, the inspiration-based approach, and the strategy-oriented approach tailored to fragile crisis contexts. Originality/Value. The paper delves into the existential challenges and ethically justified opportunities inherent in adopting the combined approach of facilitation, underlining the nuanced dynamics inherent in resilient change facilitation.
... The "facilitation" construct is an important aspect of the i-PARIHS framework required to link all of the constructs together to make the implementation both successful and sustainable [16]. Facilitation is defined as a technique that supports the implementation process by working across professional and organisational boundaries [47,48]. The essential attributes of a facilitator in our context includes strong interpersonal skills, a good understanding of patient needs and services availability, good communication with management and the ability to engage with patients to facilitate change [17,48]. ...
... Facilitation is defined as a technique that supports the implementation process by working across professional and organisational boundaries [47,48]. The essential attributes of a facilitator in our context includes strong interpersonal skills, a good understanding of patient needs and services availability, good communication with management and the ability to engage with patients to facilitate change [17,48]. Our inductive analysis identified that the managers acknowledged that the clinician delivering the targeted care navigation had these attributes. ...
We aimed to explore managerial and project staff perceptions of the pilot implementation of an algorithm-supported care navigation model, targeting people at risk of hospital readmission. The pilot was implemented from May to November 2017 at a Victorian health service (Australia) and provided to sixty-five patients discharged from the hospital to the community. All managers and the single clinician involved participated in a semi-structured interview. Participants (n = 6) were asked about their perceptions of the service design and the enablers and barriers to implementation. Interviews were transcribed verbatim and analysed according to a framework approach, using inductive and deductive techniques. Constructed themes included the following: an algorithm alone is not enough, the health service culture, leadership, resources and the perceived patient experience. Participants felt that having an algorithm to target those considered most likely to benefit was helpful but not enough on its own without addressing other contextual factors, such as the health service’s capacity to support a large-scale implementation. Deductively mapping themes to the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework highlighted that a formal facilitation would be essential for future sustainable implementations. The systematic identification of barriers and enablers elicited critical information for broader implementations of algorithm-supported models of care.
... In doing this, it must bridge the diverse perspectives, values and identities encountered; co-production requires careful facilitation (Chambers et al., 2021). Skilled facilitators play an important role as they design and implement an inclusive approach to engage and give voice to diverse stakeholders and to link both scientific knowledge and social actors' perspectives to enhance openness, iterative co-learning, and idea generation (Argyris, 2002(Argyris, , 1991Thorburn et al., 2011;Harvey et al., 2002;Brouwer et al., 2016). ...
... Group decision making outcomes achieved through participatory processes consider the differences in knowledge, perspectives, opinions, values and uncertainties from all stakeholders (Black et al., 2019). Skilled facilitators use a range of interpersonal and group skills to enable them to navigate the different ways of knowing and doing among participants, create space for open discussion, enhance trust and collaboration (Harvey et al., 2002;Nielsen, 2012;Reed and Abernethy, 2018). When individuals lead groups but do not have facilitation skills, they do not guide the discussion so members voices may not be included, power dynamics are not managed, and diverse knowledge may not be integrated. ...
Shifting the relationship between science and decision making is a key challenge for sustainable development. We conducted a two-part behavioural study linked to the preparation of the Kenya Agroforestry Strategy. Two virtual workshops followed a data visualisation preference survey of 174 technical officers to compare the influence of a peer-led and a facilitated workshop on inclusive, evidence-based decision making. A post-workshop survey, facilitator or observer reports, coded transcriptions of group discussions, root causes capturing social actor perspectives, and strategy content were analysed. Results from the visualisation preference survey indicate that most respondents preferred more straightforward displays like tables and bar charts over the more complex ridge and box plots. Limited exposure to diverse visualisation formats calls for capacity development and innovative ways to share data in multiple formats. Engaging scientists in co-production processes allows more complex data to be accessed and understood by decision makers. Triangulation across diverse data sources associated with the workshops indicates facilitated groups had greater inclusion of participants and better integrated scientific and social actor perspectives in the strategies they developed. The importance of skilled facilitators and engagement processes are therefore highlighted. Small workshop sample sizes and complex interactions indicate that further studies are needed to validate our findings, but the results of this study provide valuable insights for knowledge translation and social learning as part of co-production to support inclusive, evidence-based decision making in agricultural and environmental policy processes.
... It is important to note, that for the purposes of the study and associated conceptual framework, a more inclusive definition of facilitation was adopted. Specifically, Harvey et al. (2002) proposed, "the facilitator role is about supporting people to change their practice" (p. 585). ...
... This can be through observational data collection; there are many tools available, such as the Context Assessment Index (CAI) [40] applying quantitative ranking (ordinal data) of the workplace environment, or the example of the Workplace Culture Critical Analysis Tool (WCCAT) [41] for qualitative feedback mechanisms. Once the context has been researched, the findings will feed into the situational facilitation [42][43][44] of implementing change at a local contextual level [45][46][47] However, other theories, models, and frameworks can be adopted for research into addressing the influences upon radiographers' behaviour in the clinical workplace of resistance to change and adoption of EBP. Away from the local context exploration, research into identifying the factors (barriers and facilitators) that influence specific behavioural determinants to prioritise and target for change could adopt the Theoretical Domains Framework (TDF) [47], which can also be applied to determine cognitive, affective, social, or environmental influences that inhibit change adoption. ...
... 305). 84 Furthermore, it is essential that facilitators are equipped with the necessary skills to facilitate the activation of diverse learning modes. To illustrate, in instances of contention between stakeholders, as evidenced in our study, facilitators must possess the capacity to discern which disagreements may require to be resolved through decisions by higher authorities or by monitoring (ie, by activating hierarchical learning), which ones can be resolved through scientific evidence or expert opinion (ie, by activating epistemic learning), and which ones can be left open for discussion (ie, by activating reflexive learning) or negotiation, including with the right approach (ie, by activating learning through bargaining). ...
Introduction
Achieving universal health coverage (UHC) through an effective health financing system is a challenge for many low-income countries. Learning is key to success due to many uncertainties and unknowns. Using the case of translating strategic health purchasing into policy and practice in Burkina Faso, our study seeks to understand how policy learning can shape policy processes and outcomes.
Methods
We used a qualitative case study design and Dunlop and Radaelli’s conceptualisation of policy learning to identify which modes of learning did or did not occur, what helped or hindered them and the resulting policy outcomes. Dunlop and Radaelli frame policy learning as epistemic, reflexive, negotiative or hierarchical. We collected data through documentary review and in-depth individual interviews with 21 key informants. We analysed the data manually using pattern-matching techniques.
Results
The introduction of strategic health purchasing in Burkina Faso was initially seen as an opportunity to reduce the fragmentation of the health financing system by coupling a performance-based financing scheme and a user fee exemption policy. However, this has faltered, and our findings suggest that an inability to harness all modes of learning has led to blockages. Indeed, while reflective learning was present, epistemic, hierarchical and learning through bargaining were absent, preventing national policy actors from defending their own policy or scheme from reaching compromises. But thanks to facilitating processes led by a well-resourced organisation and contextual elements that encouraged the emergence of more pluralistic modes of learning, some progress was achieved in operationalising strategic health purchasing.
Conclusions
Some modes of learning seem to be overlooked in countries’ efforts to achieve UHC. Facilitation techniques and initiatives that encourage the use of all modes of learning, while supporting countries to take full ownership and responsibility for consolidating their own learning health systems, should be promoted.
... This primed clinics with the skills and potentially the resources to adapt their healthcare delivery rapidly (Group 2). These findings suggest the need for supporting increased capacity for QI in CHCs, provide trainings and internal or external support [31][32][33][34] to increase preparedness for rapid uptake of a new care delivery system, like telemedicine. ...
Objective
To describe telemedicine use patterns and understand clinic’s approaches to shifting care delivery during the COVID-19 pandemic.
Methods
We used electronic health record data from 203 community health centers across 13 states between 01/01/2019 and 6/31/2021 to describe trends in telemedicine visit rates over time. Qualitative data were collected from 13 of those community health centers to understand factors influencing adoption and implementation of telemedicine.
Results
Most clinics in our sample were in urban areas (n = 176) and served a majority of uninsured and publicly insured patients (12.8% and 44.4%, respectively) across racial and ethnic minority groups (16.6% Black and 29.3% Hispanic). During our analysis period there was a 791% increase in telemedicine visits from before the pandemic (.06% pre- vs 47.5% during). A latent class growth analysis was used to examine differences in patterns of adoption of telemedicine across the 203 CHCs. The model resulted in 6 clusters representing various levels of telemedicine adoption. A mixed methods approach streamlined these clusters into 4 final groups. Clinics that reported rapid adoption of telemedicine attributed this change to leadership prioritization of telemedicine, robust quality improvement processes (eg, using PDSA processes), and emphasis on training and technology support.
Conclusions
In response to the COVID-19 pandemic, telemedicine adoption rates varied across clinics. Our study highlight that organizational factors contributed to the clinic’s ability to rapidly uptake and use telemedicine services throughout the pandemic. These approaches could inform future non-pandemic practice change and care delivery.
... Another potential unintended consequence of this prominence of specialist teams might be the loss of an integrated approach to VAD care by the generalist team, detached from VAD selection, insertion or maintenance, and therefore prone to deliver fragmented and 'taskified' care (Blanco-Mavillard et al., 2022;Castro-Sanchez et al., 2014). Even better use of resources would be possible if specialist teams were leaders in the implementation of quality improvement interventions in clinical settings, which is a complex and multifaceted phenomenon that requires adequate competencies (Harvey et al., 2002;Nilsen, 2015). Whilst the professionals in specialist teams currently have the knowledge and skills to train and educate peers and other healthcare workers, as well as carers and patients, implementation competencies and proficiency among these teams are yet to be determined. ...
Background
Optimal selection of vascular access devices is based on multiple factors and is the first strategy to reduce vascular access device‐related complications. This process is dependent on behavioural and human factors. The COM‐B (Capability, Opportunity, Motivation, Behaviour) model was used as a theoretical framework to organize the findings of this systematic review.
Methods/Aims
To synthesize the evidence on determinants shaping the optimal selection of vascular access devices, using the COM‐B behavioural model as the theoretical framework.
Design
Systematic review of studies which explore decision‐making at the time of selecting vascular access devices.
Data Sources
The Medline, Web of Science, Scopus and EbscoHost databases were interrogated to extract manuscripts published up to 31 December 2021, in English or Spanish.
Results
Among 16 studies included in the review, 8/16 (50%) focused on physical capability, 8/16 (50%) psychological capability, 15/16 (94%) physical opportunity, 12/16 (75%) social opportunity, 1/16 (6%) reflective motivation and 0/16 (0%) automatic motivation. This distribution represents a large gap in terms of interpersonal and motivational influences and cultural and social environments. Specialist teams (teams created for the insertion or maintenance of vascular access devices) are core for the optimal selection of vascular access devices (75% physical capability, 62% psychological capability, 80% physical opportunity and 100% social opportunity).
Conclusion
Specialist teams predominantly lead all actions undertaken towards the optimal selection of vascular access devices. These actions primarily centre on assessing opportunity and capability, often overlooking motivational influences and social environments.
Implications for the Profession and/or Patient Care
A more implementation‐focused professional approach could decrease inequity among patients and complications associated with vascular access devices.
Impact
Optimal selection of vascular access devices is the primary strategy in mitigating complications associated with these devices.
There is a significant disparity between interpersonal and motivational influences and the cultural and social environments. Furthermore, specialized teams play a pivotal role in facilitating the optimal selection of vascular access devices.
The study can benefit institutions concerned about vascular access devices and their complications.
Reporting Method
This review followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines.
Patient or public contribution
No Patient or Public Contribution.
What does this article contribute to the wider global clinical community?
Optimal selection of vascular devices remains a growing yet unresolved issue with costly clinical and patient experience impact.
Interventions to improve the optimal selection of vascular devices have focused on training, education, algorithms and implementation of specialist vascular teams; alas, these approaches do not seem to have substantially addressed the problem.
Specialist vascular teams should evolve and pivot towards leading the implementation of quality improvement interventions, optimizing resource use and enhancing their role.
... Esta observación corrobora estudios previos según los cuales el conocimiento de las GPC no es suficiente para asegurar su cumplimiento (Grimshaw, 1999;Melnyk, Fineout-Overholt, Stillwell, & Williamson, 2010;Straus, Tetroe, & Graham, 2013). En su lugar, se debe tener en cuenta una amplia gama de factores que pueden producir un cambio de comportamiento, como los que se han evaluado en la presente tesis (Ajzen, 1991;Harvey & Kitson, 2016;Harvey et al., 2002;Rashidian & Russell, 2011) y que ayudan a comprender cómo las EPAH consiguen realizar una verdadera transferencia del conocimiento a la práctica en entornos organizacionales complejos (Fencl & Matthews, 2017). ...
Introduction. The incorporation of Evidence-Based Clinical Practice (EBCP) into daily decision-making of registered nurses continues to be a challenge for the health system. Contributing factors are usually related to the organizational culture, the characteristics of the professional or those intrinsic to the evidence itself. All this increases the variability in clinical practice since many times decision-making is based solely on the experience and judgment of the nurse. The incorporation of advanced practice nurses is a strategy used by many health systems for various purposes since they can reduce the variability in clinical practice and therefore improve clinical results. The present study implements a complex intervention, based on proven effective theories so that the incorporation of this figure in hospitalization units is a success in improving implementation and improving good practices.
Aim. To evaluate the inclusion of an Advanced Practice Hospitalization Nurse (APHN) into hospitalization units as a facilitator of the EBCP by registered nurses.
Methods. A quasi-experimental study was developed in which the clinical indicators derived from two clinical practice guidelines (CPG) that measured the nursing care process in units with and without the presence of APHN were compared. Likewise, the conditions of the work environments were evaluated with the PES-NWI instrument, as well as the attitudes, skills and perceptions of clinical nurses in EBCP through the use of the HS-EBP instrument. The study also measured the competency development of the APHN with the IECEPA instrument and identified the implementation strategies used to achieve a change in clinical practice. The i-PARIHS framework and the Theory of Planned Behavior (TPB) were used as theoretical frameworks that guided the planning, execution, and evaluation of the proposed intervention.
Results. An increase in adherence to the recommendations of both CPG was observed in the units with APHN. The perception of the work environment and the EBCP of the APHN group has improved in a statistically significant way, as well as their level of competence in advanced practice. 13 strategies and 52 behavior change techniques used in the implementation process were identified. The main activities have been aimed at increasing the knowledge and skills of registered nurses about the CPG, mentoring and support in decision-making, feedback on results, promoting a critical spirit in their own practice and teamwork.
Conclusions. The incorporation of APHN to hospital units has shown a clear improvement in the adoption of EBCP, which has translated into an improvement in clinical indicators of patient care. The focus on two CPG illustrates the potential benefits of this figure in terms of implementing evidence and promoting adherence to the CPG among other members of the nursing team. The difference in perception between professionals who practice in different categories shows a tendency to value more favorably the items that measure the PES-NWI and HS-EBP instruments as responsibility within the organization increases. The good results in the clinical indicators are the product of a real process of behavior change of registered nurses towards EBCP, that has been facilitated by the APHN, through a structured and effective intervention that has implied the use of a set of methods and TPB-based behavior change techniques and different implementation strategies.
Keywords. Evidence-Based Practice; Implementation Science; Advanced Practice Nursing; Work environment; Clinical Practice Guideline; Pressure Ulcer; Vascular Access Devices; Implementation strategies.
... Participatory Design as a design discipline builds on the principles of democratic and power balanced participation of stakeholders in the design process of technologies that will influence them and, as such, relies on facilitation to enable the interaction of people for and with which the design should happen. Harvey et al. [9] have described facilitation as a dichotomic role, moving from doing tasks for others to enabling others. Facilitators in PD workshops by principle enable others. ...
While democratic practices, balancing powers, mutual learning and tools and techniques are the principles of Participatory Design (PD), they are all influenced by the practice of PD “facilitation” and the role of the facilitator(s). Facilitation in PD has been usually studied as a single entity with a facilitator that faces dilemmas in her/his role in relation to PD participants and her/his own motives and values. In this paper, we contribute to PD facilitation practice literature by studying facilitation as collaboration work compounded by many entities. We conducted a reflective analysis of the facilitation practices in two PD projects that we have managed. We found that PD projects have a multitude of facilitators. These facilitators belong to four categories: user experts, domain experts, PD experts and assistant facilitators. In time and in different PD activities facilitators may join or leave the project and also shift between categories while their expertise expands. We define this as “the network of facilitators” and discuss how such a perspective can help to improve the facilitation practice in PD.Keywordsparticipatory designfacilitationreflective practicenetwork of facilitators
... However, as with many new practices, the implementation of the MPAI-4 in clinical settings can be complex, multi-level, and thus, difficult to achieve. The implementation strategies that are targeted to the local context [35][36][37] may help to promote the adoption of evidence-informed practices, 38 to improve patient and provider experiences related to the Quadruple aim framework 39 40 and ultimately, to inform the implementation success. In fact, the Quadruple aim framework describes the importance of healthcare improvements and transformation efforts of the healthcare system, including improving the health of populations, patients' experience of care, healthcare providers' experience and reducing the cost of care with the intention of improving health equity. ...
Introduction
Stroke is a leading cause of morbidity and mortality worldwide, placing an immense burden on patients and the health system. Timely access to rehabilitation services can improve stroke survivors’ quality of life. The use of standardised outcome measures is endorsed for optimising patient rehabilitation outcomes and improving clinical decision-making. This project results from a provincially mandated recommendation to use the fourth version of the Mayo-Portland Adaptability Inventory (MPAI-4) to measure changes in social participation of stroke survivors and to maintain commitment to evidence-informed practices in stroke care. This protocol outlines the implementation process of the MPAI-4 for three rehabilitation centres. The objectives are to: (a) describe the context of MPAI-4 implementation; (b) determine clinical teams’ readiness for change; (c) identify barriers and enablers to implementing the MPAI-4 and match the implementation strategies; (d) evaluate the MPAI-4 implementation outcomes including the degree of integration of the MPAI-4 into clinical practice and (e) explore participants’ experiences using the MPAI-4.
Methods and analysis
We will use a multiple case study design within an integrated knowledge translation (iKT) approach with active engagement from key informants. Each case is a rehabilitation centre implementing MPAI-4. We will collect data from clinicians and programme managers using mixed methods guided by several theoretical frameworks. Data sources include surveys, focus groups and patient charts. We will conduct descriptive, correlational and content analyses. Ultimately, we will analyse, integrate data from qualitative and quantitative components and report them within and across participating sites. Results will provide insights about iKT within stroke rehabilitation settings that could be applied to future research projects.
Ethics and dissemination
The project received Institutional Review Board approval from the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal. We will disseminate results in peer-reviewed publications and at local, national and international scientific conferences.
... The term "facilitator" is also used for interventions dedicated to bridge barriers such as electronic reminders that enable the end-user's uptake and adherence to evidence-based practice guidelines (5,6). Internal facilitators (IFs), a topic addressed here, are people assigned to facilitate knowledge implementation in their organisations (7)(8)(9)(10). That is, IFs help others adopt and sustain the use of evidence-based practices. ...
Numerous endeavours to ensure that day-to-day healthcare is both evidence-based and person-centred have generated extensive, although partial, comprehension of what guarantees quality improvement. To address quality issues, researchers and clinicians have developed several strategies as well as implementation theories, models, and frameworks. However, more progress is needed regarding how to facilitate guideline and policy implementation that guarantees effective changes take place in a timely and safe manner. This paper considers experiences of engaging and supporting local facilitators in knowledge implementation. Drawing on several interventions, considering both training and support, this general commentary discusses whom to engage and the length, content, quantity, and type of support along with expected outcomes of facilitators' activities. In addition, this paper suggests that patient facilitators could help produce evidence-based and person-centred care. We conclude that research about the roles and functions of facilitators needs to include more structured follow-ups and also improvement projects. This can increase the speed of learning with respect to what works, for whom, in what context, why (or why not), and with what outcomes when it comes to facilitator support and tasks.
... Context as per the PARIHS framework refers to "the environment in which the proposed change is to be implemented" (20) . The main contextual factors contributing to successful transformation of evidence into practice are culture, leadership and evaluation (21) . Results from the quantitative strand revealed that information processing, specifically, clarity regarding readiness of the organizational structure, the bylaws, and new leadership roles were the most prominent hindrances to change. ...
Background: A study in 2014 on systems and processes needed to enhance the quality of health professions education during a period of transition at the Ministry of Health Educational Institutes; now known as Oman College for Health Sciences and the Higher Institute for Health Specialties, revealed positive expectations of staff towards the upgrade to a four-year college. However, staffs were uncertain about how they would manage the change, resulting in adverse psychological impact. The purpose of this study was to evaluate the overall readiness for change at Oman College of Health Sciences (OCHS) and the Higher Institute for Health Specialties (HIHS) during its second phase of transition.Aim of the study: to evaluate the overall readiness for change at Oman College of Health Sciences (OCHS) and the Higher Institute for Health Specialties (HIHS) during its second phase of transition.Methodology: a mixed method case study approach was conducted during the period of August 2017 to March 2019. For the quantitative part of the study, the authors used the Organizational Change Readiness Assessment OCRA tool to explore the barriers and drivers regarding change implementation experienced by employees at (OCHS) during a period of transition. This was followed by semi-structured interviews with five participants in leadership position of OCHS and the HIHS.Results: of 381 questionnaires distributed, 128 were completed; a response rate of 33.6%. The quantitative findings identified inhibitors that had the highest impact towards successful change implementation to be information processes, organizational structure and task processes, and human resources system, while the qualitative analysis resulted in two main themes, organizational readiness for change, and individuals’ readiness for change.Conclusion: Based on the results, it was apparent that the existing change and transition management strategies require further planning. Study findings indicated that readiness for change was influenced by organizational and behavioral factors. Both aspects were accompanied by challenges and possible opportunities regarding change implementation.Recommendations: This study recommended that other future studies should be conducted within the scope of this study to include students and external stakeholders.
Voice-based social media platforms that enable attendees to have real-time, ephemeral interactions with each other—such as X-Spaces, Discord, and Clubhouse—have seen considerable growth in recent years. While prior research on these spaces has predominantly focused on moderating harms, our work seeks to understand emergent practices employed by hosts to proactively shape their discussion space— focusing on the facilitation aspect of moderation duties. Drawing on facilitation strategies, we study these practices through three comprehensive studies using mixed-methods: survey of social-audio users, co-design interviews, and analyzing training sessions for hosts. Our findings reveal insights into the issues faced by hosts and attendees, current facilitation practices, opinions on technological solutions, and factors that could be responsible for some of the identified issues such as the available training for hosts. We found that hosts themselves are often significant sources of issues due to practices such as focusing more on self-promotion than facilitating discussions. In addition, host training sessions seem to encourage behaviors that contribute to the negative perception of hosts. We draw on outcomes from co-design interviews to guide the design of future tools to support hosts in facilitating social-audio spaces. Our findings provide insights that could help create a more positive experience for both hosts and attendees.
Background
Home-based care for patients diagnosed in emergency departments (EDs) with low-risk pulmonary embolism (PE) is an evidence-based, guideline-recommended practice that is not widely adopted in the US. Few studies demonstrate how this care pathway can be implemented effectively or test whether implementation strategies can address known barriers. Further, prior studies have lacked diversity in population and health system type and did not integrate theory-informed implementation frameworks. Although essential for establishing the evidence base for safe home management of low-risk acute PE, these studies have thus fallen short of guiding broad dissemination and equitable implementation. To bridge this gap, we are conducting a pragmatic multi-site implementation trial, guided by implementation science theory and frameworks, across twelve diverse hospital settings to assess the effectiveness of new care pathways for patients with low-risk PE presenting to EDs.
Methods/design
The study uses a cluster-randomized stepped wedge trial design to investigate a set of implementation strategies to support establishing low-risk PE pathways in 12 EDs. Clusters of three hospitals were randomly assigned to one of four start dates, staggered over a 12-month period. During an initial three-month pre-implementation period, we will work with site champions to identify key site personnel and understand site barriers and facilitators. We will then tailor the care pathway to local needs and capabilities. During the six-month active implementation period, we will provide coaching to help sites implement a multi-component intervention informed by behavioral economics intended to address multi-level (site, provider, patient) barriers and integrate the new care pathway for discharging low-risk PE patients. Sites are then followed for a minimum of 12 months post-implementation. Our primary aim is to assess the change in discharge rates of patients with acute PE pre- and post-implementation. Secondary and exploratory aims will assess change in patient safety outcomes along with other key implementation outcomes guided by the RE-AIM framework.
Discussion
This study expands upon prior effectiveness research to tailor, implement, and robustly evaluate a multi-component implementation intervention for diverse health systems aiming to increase guideline-based outpatient management of low-risk PE. Broad-scale implementation in the US could avert up to 100,000 hospitalizations annually.
Trial registration
Clinicaltrials.gov (NCT06312332), registered on March 13, 2024.
Background
Recently, numerous initiatives have been taken to improve food and meals for hospital inpatients. Research providing in-depth knowledge on leading such improvement initiatives and implementing changes, specifically through facilitation within this multilevel context, is essential. This study aims to explore nutrition leaders’ experiences in implementing changes to improve food and meal provision for hospital inpatients, focusing on facilitation activities.
Method
This is a qualitative interview study within the social constructivist paradigm. Participants were recruited through professional networks, advertisements, and snowballing. Eighteen semi-structured interviews were conducted individually with participants in leadership roles of food and meal improvement initiatives at Swedish hospitals. The interviews were transcribed verbatim and analysed thematically through an i-PARIHS lens.
Results
Three themes of facilitation activities were identified: ‘Building Relationships’, ‘Placing Food and Meals on the Agenda’, and ‘Cultivating Skills’. Building relationships involved establishing connections between the service and clinical divisions. Creating common structures and multidisciplinary teamwork enabled collaboration across organisational boundaries. Placing food and meals on the agenda involved both initial and ongoing communication activities, as food and meal tasks were often considered low priority. Cultivating skills encompassed creating learning opportunities for implementing lasting changes, tailored to specific contexts and adopted within everyday practices.
Conclusions
Collaboration between foodservice and clinical professionals, along with the dissemination of knowledge, appears to be important for implementing changes. Active leadership supports successful implementations by providing structured approaches, including feedback systems, and by contributing to the recognition of improvement initiatives, according to experiences shared during interviews.
Introduction
Translating health research into clinical practice is a complex process aimed at enhancing healthcare quality and patient outcomes. The terminology surrounding this process is varied and often used interchangeably, leading to minimal consensus on the activities encompassed by each term.
Objectives
This study aims to examine existing taxonomies and websites for operational definitions related to health research translation, culminating in a comprehensive synopsis of terms specific to this field.
Design
In 2019, a literature search was conducted using databases such as PubMed and CINAHL, along with relevant government and non-governmental organisation (NGO) websites, including grey literature. The search focused on English-language publications defining health research translation from 2000 onward and was updated in 2023. One author conducted the search, employing a mix of free-text and database-specific terms. Two authors independently evaluated the results for inclusion. Relevant data were extracted to aid in sorting and prioritising terminology based on frequency. A concept analysis approach, developed by Foley and Davis and informed by Rodgers’ seven phases, was used to map the nomenclature.
Results
A total of 51 papers were analysed, revealing that the most frequently used terms for health research translation were knowledge translation (KT), implementation and translational research. Both evidence-based healthcare and KT describe the process of integrating evidence into practice, positioning them as analogous. Two major domains were identified: practice and science, with practice-related language further categorised into people-focused, process-focused and outcome-focused.
Conclusions
This paper presents a conceptual nomenclature map that serves as a foundation for developing a consensus-driven ontology for health research translation. The framework highlights how language can be categorised into common domains, fostering meaningful communication across diverse groups and entities.
i>Pressure exists in health services research for teams to collect and synthesize qualitative data rapidly. Lacking is a standard process to aid team-based debriefings during the early stages of data collection in real time. We propose a systematic team-based process and template for use during the data collection phase of qualitative studies and demonstrate the utility of the approach using a Veteran’s Administration evaluation study. Guided Team Discussion (GTD) can improve the efficiency of team debriefing through a facilitated process that standardizes discussion format and sharing of learnings amongst the team on recently completed interviews. Notetaking of team debriefings is facilitated by the GTD template, which links team discussions to particular interviews and study time points. The GTD would be useful to researchers and clinicians who conduct health services studies with qualitative methods that require rapid recruitment and synthesis of results and to standardize notetaking of team debriefings.</i
Background
The National Healthcare Service (NHS) radiology service delivery in London is representative of the current pressures and challenges faced in England of Musculoskeletal (MSK) X-ray reporting workforce shortages, and national turnaround time (TATs) targets. The implementation project evaluated facilitation as a strategy to achieve the NHS England 50% target for all MSK X-rays to be reported by radiographers.
Methods
The project was an eight-month multi-centre (n = 5 London NHS Trusts) study applying the Promoting Action on Research Implementation in Health Services (PARIHS) framework with embedded mixed-methods evaluation. Initial observational data using the Context Assessment Index (CAI) tool and the Workplace Culture Critical Analysis Tool (WCCAT) set the implementation interventions which comprised external facilitation, to support internal facilitators action learning activities. Evaluation data comprised monthly reporting performance, systems mapping, interviews.
Results
System mapping allowed a perspective beyond the characteristics of the NHS Trusts involved (small single site hospitals to large multi-sites hospitals) of mixed clinical duties, scope of practice, reporting session allocation, and equipment used. CAI scores for workplace culture demonstrated = 73.7% (SD 6.8; 95%CI 8.49), leadership scored = 69.3% (SD 7.3; 95% CI 9.17), and evaluation scored = 75.5% (SD 6.9; 95% CI 98.63). WCCAT observations provided themes for facilitation focusing on remote reporting, insourcing backlogs, prioritising worklists to reduce breaching TATs, reporting metrics, and reducing auto reporting. The combined reporting of MSK X-rays by London radiographers during this study achieved = 53.7%.
Conclusion
This study had an innovative approach using an implementation facilitation framework to improve service delivery. The clinical workplace context in which MSK X-ray reporting by radiographers occurs was key to implementing change. The complexities of sustaining and upscaling MSK X-ray reporting by radiographers to meet the NHS England target of 50% are varied and require local champions to facilitate and drive change at organisational levels. It is recommended that there are dedicated ‘resources’ to sustain implementations with a community of practice for support. Workplace leadership and stakeholder networks are needed to sustain improved working practices and embrace regular evaluation and monitoring of service delivery performance.
This monograph reports the results of a three-year multiple case study of nine knowledge-to-action (KTA) initiatives mobilized in communities of practice (C0Ps) operating in Ontario's seniors' health system. A multiple case study design was used to conduct nine case studies through a combination of case study and ethnographic methods. Deductive analytical methods were used to answer two broad research questions about the KTA processes mobilized through the CoPs, and about the roles played by CoP members and other stakeholders. Inductive analytical methods were used to reveal the patterns of interaction characteristic of the CoPs. These CoPs acted as flexible and temporary social forms with specific characteristics and processes allowing them to integrate explicit and tacit knowledge to resolve the unique contextual challenges of health practices. Our findings suggest that these CoPs often developed a double-loop learning process that is well suited to responding to adaptive challenges and wicked problems. Conclusions from this qualitative study are not generalizable to all situations and contexts. Findings suggest that the concept of "knowledge-to-action" be supplemented by a concept of "action-to-knowledge" that recognizes that important initiatives are often incubated in the action of health care delivery when dedicated professionals come together to tackle intractable issues. This is the first multiple case study of CoPs in the Canadian health system. The study shows that CoPs can act as the junction for the rational epistemology of science and the narrative epistemology of practice.
Evidence-based approaches to screening and treatment for unhealthy alcohol use have the potential to reduce morbidity and mortality but are currently underutilized in primary care settings. To support implementation of screening, brief intervention, and referral to treatment (SBIRT) and medication-assisted treatment for alcohol use disorder (MAUD) by identifying goals co-developed by clinics and practice facilitators in a flexible implementation study. In a pragmatic implementation study, we used practice facilitation to support the implementation of SBIRT and MAUD in 48 clinical practices across Oregon, Washington, and Idaho. Our study used a tailored approach, in which facilitators and clinics co-identified implementation goals based on clinic needs. We used clinic contact logs, individual interviews, group periodic reflections with practice facilitators, and exit interviews with clinic staff to inform qualitative analysis. With support from practice facilitators, clinics identified goals spanning SBIRT, MAUD, reporting, targeted patient outreach, and quality improvement capacity. Goals addressed both the technical (e.g. data tracking) and social (e.g. staff training) aspects of SBIRT and MAUD. A decision tree summarizes emergent findings into a tool to support future implementation of SBIRT in primary care settings. A facilitator-supported, tailored approach to SBIRT implementation enabled clinics to identify a variety of goals to improve SBIRT and MAUD implementation. These identified priorities, along with a decision tree describing the hierarchical structure of these goals, could support future implementation efforts.
The FLOW program assists mental health providers in transitioning recovered and stabilized specialty mental health (SMH) patients to primary care to increase access to SMH care. In a recent cluster-randomized stepped-wedge trial, nine VA sites implemented the FLOW program with wide variation in implementation success. The goal of this study is to identify site-level factors associated with successful implementation of the FLOW program, guided by the Consolidated Framework for Implementation Research (CFIR). We used the Matrixed Multiple Case Study method, a mixed-methods approach, to compare key metrics hypothesized to impact implementation that were aligned with CFIR. Based upon the number of veterans transitioned at each site, we categorized two sites as higher implementation success, three as medium, and four as lower implementation success. Themes associated with more successful implementation included perceptions of the intervention itself (CFIR domain Innovation), having a culture of recovery-oriented care and prioritizing implementation over competing demands (CFIR domain Inner Setting), had lower mental health provider turnover, and had an internal facilitator who was well-positioned for FLOW implementation, such as having a leadership role or connections across several clinics (CFIR domain Characteristics of Individuals). Other variables, including staffing levels, leadership support, and organizational readiness to change did not have a consistent relationship to implementation success. These data may assist in identifying sites that are likely to need additional implementation support to succeed at implementing FLOW.
Background
Depression is the most diagnosed mental health condition among people living with HIV. Collaborative care is an effective intervention for depression, typically delivered in primary care settings. The HIV Translating Initiatives for Depression into Effective Solutions (HITIDES) clinical intervention involves a depression care team housed off-site that supports depression care delivery by HIV care providers. In a randomized controlled trial, HITIDES significantly improved depression symptoms for veterans living with HIV and delivered cost savings. However, no HIV clinics in the Veterans Health Administration (VHA) have implemented HITIDES; as such, it is unclear what implementation strategies are necessary to launch and sustain this intervention.
Methods
This hybrid type-3 effectiveness-implementation trial examines the implementation and effectiveness of HITIDES in 8 VHA HIV clinics randomly assigned to one of two implementation arms. Each arm uses a different implementation strategy package. Arm 1 includes an intervention operations guide; an on-site clinical champion who, with the help of a peer community of practice, will work with local clinicians and leadership to implement HITIDES at their site; and patient engagement in implementation tools. Arm 2 includes all strategies from Arm 1 with assistance from an external facilitator. The primary implementation outcomes is reach; secondary outcomes include adoption, implementation dose, depressive symptoms, and suicidal ideation. We will conduct a budget impact analysis of the implementation strategy packages. We hypothesize that Arm 2 will be associated with greater reach and adoption and that Arm 1 will be less costly.
Discussion
Preliminary work identified implementation strategies acceptable to veterans living with HIV and HIV care providers; however, the effectiveness and cost of these strategies are unknown. While the depression care team can deliver services consistently with high quality, the ability of the depression care team to engage with HIV care providers at sites is unknown. Findings from this study will be used to inform selection of implementation strategies for a broad rollout to enhance depression and suicide care for people living with HIV.
Trial registration
ClinicalTrials.gov ID: NCT05901272, Registered 10 May 2023, https://clinicaltrials.gov/study/NCT05901272
Objective
To determine the budget impact of implementing multidisciplinary complex pain clinics (MCPCs) for Veterans Health Administration (VA) patients living with complex chronic pain and substance use disorder comorbidities who are on risky opioid regimens.
Data Sources and Study Setting
We measured implementation costs for three MCPCs over 2 years using micro‐costing methods. Intervention and downstream costs were obtained from the VA Managerial Cost Accounting System from 2 years prior to 2 years after opening of MCPCs.
Study Design
Staff at the three VA sites implementing MCPCs were supported by Implementation Facilitation. The intervention cohort was patients at MCPC sites who received treatment based on their history of chronic pain and risky opioid use. Intervention costs and downstream costs were estimated with a quasi‐experimental study design using a propensity score‐weighted difference‐in‐difference approach. The healthcare utilization costs of treated patients were compared with a control group having clinically similar characteristics and undergoing the standard route of care at neighboring VA medical centers. Cancer and hospice patients were excluded.
Data Collection/Extraction Methods
Activity‐based costing data acquired from MCPC sites were used to estimate implementation costs. Intervention and downstream costs were extracted from VA administrative data.
Principal Findings
Average Implementation Facilitation costs ranged from 640 per month for each site. Upon opening of three MCPCs, average intervention costs per patient were significantly higher than the control group at two intervention sites. Downstream costs were significantly higher at only one of three intervention sites. Site‐level differences were due to variation in inpatient costs, with some confounding likely due to the COVID‐19 pandemic. This evidence suggests that necessary start‐up investments are required to initiate MCPCs, with allocations of funds needed for implementation, intervention, and downstream costs.
Conclusions
Incorporating implementation, intervention, and downstream costs in this evaluation provides a thorough budget impact analysis, which decision‐makers may use when considering whether to expand effective programming.
Objective
To synthesise current knowledge about the role of external facilitators as an individual role during the implementation of complex interventions in healthcare settings.
Design
A scoping review was conducted. We reviewed original studies (between 2000 and 2023) about implementing an evidence-based complex intervention in a healthcare setting using external facilitators to support the implementation process. An information specialist used the following databases for the search strategy: MEDLINE, CINAHL, APA PsycINFO, Academic Search Complete, EMBASE (Scopus), Business Source Complete and SocINDEX.
Results
36 reports were included for analysis, including 34 different complex interventions. We performed a mixed thematic analysis to synthesise the data. We identified two primary external facilitator roles: lead facilitator and process expert facilitator. Process expert external facilitators have specific responsibilities according to their role and expertise in supporting three main processes: clinical, change management and knowledge/research management.
Conclusions
Future research should study processes supported by external facilitators and their relationship with facilitation strategies and implementation outcomes. Future systematic or realist reviews may also focus on outcomes and the effectiveness of external facilitation.
Background:
Though the prevalence of diabetes is set to increase, most serious game solutions typically target patient self-management and education. Few games target healthcare professions education, and even fewer consider the factors that may increase their efficacies. The impact of facilitation, a prominent feature of health professions education, is examined in the context of a rehearsal-based diabetes management serious game.
Objective:
In this mixed-methods open label superiority randomised-controlled trial, we compare student performance, attitudes, and perceptions of a rehearsal-based diabetes management game for healthcare professionals.
Methods:
Student participants were randomised into two groups to play a diabetes management game. The control group played the game alone, and the intervention group played the same game alongside a facilitator tasked to moderate overall challenge levels and address queries. Both groups were administered the Flow Short Scale (FSS), a 13-item measure rated on a 7-point Likert scale ranging from 1 ("not at all") to 7 ("very much") immediately after the game. Students were then invited to voluntary focus group discussions to elicit their attitudes and perceptions of the game. Findings were subject to between-group comparisons and inductive thematic analysis respectively.
Results:
A total of 48 (26 control, 22 intervention) clinical-year undergraduates from the Lee Kong Chian School of medicine in Singapore participated in the study, with 18 continuing to the focus group discussions. FSS results indicated superiority of the intervention group for overall Flow (t = -2.17, P = .04) and the Absorption subdomain (t = -2.6, P = .01). Qualitative results indicated students viewed facilitation as helpful, appropriate, were able to identify improvable elements of the game's theoretical foundations and overall design.
Conclusions:
While serious games are efficacious means of rehearsing previously learned knowledge, facilitation allows for their efficiency to be greatly increased. Such increases are likely crucial in the coming the years with the increased digitisation of healthcare professions education and prevalence of diabetes.
Clinicaltrial:
ClinicalTrials.gov NCT05637749; https://www.clinicaltrials.gov/study/NCT05637749.
Background
Despite the known benefits of exclusive breastfeeding, global rates remain below recommended targets, with Ireland having one of the lowest rates in the world. This study explores the efficacy of Participatory Action Research (PAR) and Work-Based Learning Groups (WBLGs) to enhance breastfeeding practices within Irish healthcare settings from the perspective of WBLG participants and facilitators.
Methods
Employing a PAR approach, interdisciplinary healthcare professionals across maternity, primary, and community care settings (n = 94) participated in monthly WBLGs facilitated by three research and practice experts. These sessions, conducted over nine months (November 2021 – July 2022), focused on critical reflective and experiential learning to identify and understand existing breastfeeding culture and practices. Data were collected through participant feedback, facilitator notes, and reflective exercises, with analysis centered on participant engagement and the effectiveness of WBLGs. This approach facilitated a comprehensive understanding of breastfeeding support challenges and opportunities, leading to the development of actionable themes and strategies for practice improvement.
Results
Data analysis from WBLG participants led to the identification of five key themes: Empowerment, Ethos, Journey, Vision, and Personal Experience. These themes shaped the participants’ meta-narrative, emphasising a journey of knowledge-building and empowerment for breastfeeding women and supporting staff, underlining the importance of teamwork and multidisciplinary approaches. The project team’s evaluation highlighted four additional themes: Building Momentum, Balancing, Space Matters, and Being Present. These themes reflect the dynamics of the PAR process, highlighting the significance of creating a conducive environment for discussion, ensuring diverse engagement, and maintaining energy and focus to foster meaningful practice changes in breastfeeding support.
Conclusion
This study highlights the potential of WBLGs and PAR to enhance the understanding and approach of healthcare professionals towards breastfeeding support. By fostering reflective and collaborative learning environments, the study has contributed to a deeper understanding of the challenges in breastfeeding support and identified key areas for improvement. The methodologies and themes identified hold promise to inform future practice and policy development in maternal and child health.
Introduction
The Veterans Health Administration (VHA) established the Airborne Hazards and Open Burn Pit Registry (AHOBPR) in 2014 to address exposure concerns for veterans who have served in military operations in Southwest Asia and Afghanistan. By 2021, over 236,086 veterans completed the online questionnaire and 60% requested an AHOBPR examination. Of those requesting an exam, only 12% had an exam recorded in their medical record. This article summarizes barriers and facilitators to delivering AHOBPR exams and shares lessons learned from facilities who have successfully implemented burn pit exams for veterans.
Materials and Methods
We (I.C.C and J.H.) constructed a key performance measure of AHOBPR examination (the ratio of examinations performed in facility over examinations assigned to a facility) to identify top performing facilities and then used stratified purposeful sampling among high-performing sites to recruit a diverse set of facilities for participation. We (P.V.C. and A.A.) recruited and interviewed key personnel at these facilities about their process of administering burn pit exams. Rapid qualitative methods were used to analyze interviews.
Results
The ratio of exams performed to exams assigned ranged from 0.00 to 14.50 for the 129 facilities with available information. Twelve interviews were conducted with a total of 19 participants from 10 different facilities. We identified 3 barriers: Unclear responsibility, limited incentives and competing duties for personnel involved, and constrained resources. Facilitators included the presence of an internal facilitator, additional staff support, and coordination across a facility’s departments to provide care.
Conclusions
Gaps across many VHA facilities to provide AHOBPR exams may be understood as stemming from organizational issues related to clear delegation of responsibility and staffing issues. VHA facilities that wish to increase AHOBPR exams for veterans may need additional administrative and medical staff.
Objective:
In 2017, the Veterans Health Administration (VHA) implemented a national suicide prevention program, called Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), that uses a predictive algorithm to identify, attempt to reach, assess, and care for patients at the highest risk for suicide. The authors aimed to evaluate whether facilitation enhanced implementation of REACH VET at VHA facilities not meeting target completion rates.
Methods:
In this hybrid effectiveness-implementation type 2 program evaluation, a quasi-experimental pre-post design was used to assess changes in implementation outcome measures evaluated 6 months before and 6 months after onset of facilitation of REACH VET implementation at 23 VHA facilities. Measures included percentages of patients with documented coordinator and provider acknowledgment of receipt, care evaluation, and outreach attempt. Generalized estimating equations were used to compare differences in REACH VET outcome measures before and after facilitation. Qualitative interviews were conducted with personnel and were explored via template analysis.
Results:
Time had a significant effect in all outcomes models (p<0.001). An effect of facilitation was significant only for the outcome of attempted outreach. Patients identified by REACH VET had significantly higher odds of having a documented outreach attempt after facilitation of REACH VET implementation, compared with before facilitation. Site personnel felt supported and reported that the external facilitators were helpful and responsive.
Conclusions:
Facilitation of REACH VET implementation was associated with an improvement in outreach attempts to veterans identified as being at increased risk for suicide. Outreach is critical for engaging veterans in care.
Objective(s): To identify barriers and facilitators related to reimbursement processes, device acquisition costs, stocking, and supply of long-acting reversible contraception (LARC) from 27 jurisdictions (26 states/1 territory) participating in the Increasing Access to Contraception Learning Community from 2016 to 2018. Materials and Methods: A descriptive study using qualitative data collected through 27 semistructured key informant interviews was conducted during the final year of the learning community among all jurisdictional teams. Excerpts were extracted and coded by theme, then summarized as barriers or facilitators using implementation science methods. Results: Most jurisdictions (89%) identified barriers to reimbursement processes, device acquisition, stocking, and supply of LARC devices, and 85% of jurisdictions identified facilitators for these domains. Payment methodology challenges and lack of billing and coding processes were identified as the most common barriers to reimbursement processes. Device acquisition cost challenges and lack of delivery facility protocols for billing were the most common barriers to device acquisition, stocking, and supply of LARC. The most common facilitator of reimbursement processes was expanded payment methodology options, whereas supplemental funding for acquisition costs and protocol development were identified as the most common facilitators of device acquisition, stocking, and supply. Conclusion: Revised payment methodologies and broader health systems changes including additional funding sources and protocols for billing, stocking, and supply were used by learning community jurisdictions to address identified barriers. The learning community framework offers a forum for information exchange, peer-to-peer learning, and sharing of best practices to support jurisdictions in addressing identified barriers and facilitators affecting contraception access.
Background
Health systems have a critical role in a multi-sectoral response to domestic violence against women (DVAW). However, the evidence on interventions is skewed towards high income countries, and evidence based interventions are not easily transferred to low-and middle-income countries (LMIC) where significant social, cultural and economic differences exist. We evaluated feasibility and acceptability of implementation of an intervention (HERA—Healthcare Responding to Violence and Abuse) to improve the response to DVAW in two primary health care clinics (PHC) in Brazil.
Methods
The study design is a mixed method process and outcome evaluation, based on training attendance records, semi-structured interviews (with 13 Primary Health Care (PHC) providers, two clinic directors and two women who disclosed domestic violence), and identification and referral data from the Brazilian Epidemiological Surveillance System (SINAN).
Results
HERA was feasible and acceptable to women and PHC providers, increased providers’ readiness to identify DVAW and diversified referrals outside the health system. The training enhanced the confidence and skills of PHC providers to ask directly about violence and respond to women’s disclosures using a women centred, gender and human rights perspective. PHC providers felt safe and supported when dealing with DVAW because HERA emphasised clear roles and collective action within the clinical team. A number of challenges affected implementation including: differential managerial support for the Núcleo de Prevenção da Violência (Violence Prevention Nucleus—NPV) relating to the allocation of resources, monitoring progress and giving feedback; a lack of higher level institutional endorsement prioritising DVAW work; staff turnover; a lack of feedback from external support services to PHC clinics regarding DVAW cases; and inconsistent practices regarding documentation of DVAW.
Conclusion
Training should be accompanied by system-wide institutional change including active (as opposed to passive) management support, allocation of resources to support roles within the NPV, locally adapted protocols and guidelines, monitoring progress and feedback. Communication and coordination with external support services and documentation systems are crucial and need improvement. DVAW should be prioritised within leadership and governance structures, for example, by including DVAW work as a specific commissioning goal.
Background and Aim: This paper mainly reacts to the important factors affecting the willingness of undergraduate art and design students to participate in blended learning in three public universities in Chengdu. The study investigated latent variables including Perceived Ease of Use (PEOU), Perceived Usefulness (PU), Attitude (ATT), Effort Expectancy (EE), Social Influence (SI), Facilitating Conditions (FC), and Behavioral Intention (BI). The goal of this paper is to determine the extent to which each variable influences the target population's participation in blended learning activities. Materials and Methods: In this paper, the characteristics of anchors are classified into three dimensions: attitudes, behavioral intentions, etc., and the relationship between blended learning and students is discussed. In this paper, 488 data were collected through questionnaires and statistically analyzed, and the hypothesis was tested using SPSS and AMOS software. Results: The results of the statistical analysis confirmed all the hypotheses, with effort expectancy exhibiting the most pronounced and significant direct impact on behavioral intention. Conclusion: For art and design students to fully appreciate and acknowledge the efficacy of blended learning, college administrators and instructional staff must allocate adequate attention to the factors that wield substantial influence over instructional behavioral intentions. Moreover, they should contemplate prospective instructional modifications or reforms guided by the outcomes of this study.
Introduction
Evidence strongly suggests that orthogeriatric co-management improves patient outcomes in frail older patients with a fracture, but evidence regarding how to implement this model of care in daily clinical practice is scarce. In this paper, we first describe the implementation process and selection of implementation strategies for an orthogeriatric co-management program in the traumatology ward of the University Hospitals Leuven in Belgium. Second, we report the results of a multi-method feasibility study. This study (1) measures the fidelity towards the program's core components, (2) quantifies the perceived feasibility and acceptability by the healthcare professionals, and (3) defines implementation determinants.
Methods
Implementation strategies were operationalized based on the Expert Recommendations for Implementing Change (ERIC) guidelines. In the feasibility study, fidelity towards the core components of the program was measured in a group of 15 patients aged 75 years and over by using electronic health records. Feasibility and acceptability as perceived by the involved healthcare professionals was measured using a 15-question survey with a 5-point Likert scale. Implementation determinants were mapped thematically based on seven focus group discussions and two semi-structured interviews by focusing on the healthcare professionals' experiences.
Results
We observed low fidelity towards completion of a screening questionnaire to map the premorbid situation (13%), but high fidelity towards the other program core components: multidimensional evaluation (100%), development of an individual care plan (100%), and systematic follow-up (80%). Of the 50 survey respondents, 94% accepted the program and 62% perceived it as feasible. Important implementation determinants were feasibility, awareness and familiarity, and improved communication between healthcare professionals that positively influenced program adherence.
Conclusions
Fidelity, acceptability, and feasibility of an orthogeriatric co-management program were high as a result of an iterative process of selecting implementation strategies with intensive stakeholder involvement from the beginning.
Clinical trial registration
[ https://www.isrctn.com/ISRCTN20491828 ], International Standard Randomised Controlled Trial Number (ISRCTN) Registry: [ISRCTN20491828]. Registered on October 11, 2021.
This would be the first instance where we would be using the online web-based training session for senior citizens and the caregivers to address the commonest health issues like depression, as a result of loneliness arising among the senior citizens during the lockdown period of CoVID-19 pandemic in India and the other issue is caregiver burden, stress and strain due to burnout because of continued caretaking.
The article focusses on addressing the mental health issues arising in situations like the global pandemic, of CoVID-19 outbreak, among the senior residents and their caregivers. The lockdown period in India came along with mental health issues, which included depression in elderly with caregiver burnout and strain among the caregiver’s, due to excess caregiving. The above-mentioned health issues could have been addressed during the online training session. The tools involved here, would be web-based applications, conveyed through cell phones using this as a mode of delivery of the online training content, to the participants.
Background
Older inpatients are at high risk of hospital-associated complications, particularly delirium and functional decline. These can be mitigated by consistent attention to age-friendly care practices such as early mobility, adequate nutrition and hydration, and meaningful cognitive and social activities. Eat Walk Engage is a ward-based improvement programme theoretically informed by the i-PARIHS framework which significantly reduced delirium in a four-hospital cluster trial. The objective of this process evaluation was to understand how Eat Walk Engage worked across trial sites.
Methods
Prospective multi-method implementation evaluation on medical and surgical wards in four hospitals implementing Eat Walk Engage January 2016-May 2017. Using UK Medical Research Council guidance, this process evaluation assessed context, implementation (core components, implementation strategies and improvements) and mechanisms of impact (practice changes measured through older person interviews, structured mealtime observations and activity mapping) at each site.
Results
The four wards had varied contextual barriers which altered dynamically with time. One ward with complex outer organisational barriers showed poorer implementation and fewer practice changes. Two experienced facilitators supported four novice site facilitators through interactive training and structured reflection as well as data management, networking and organisational influence. Novice site facilitators used many implementation strategies to facilitate 45 discrete improvements at individual, team and system level. Patient interviews (42 before and 38 after implementation) showed better communication about program goals in three sites. Observations of 283 meals before and 297 after implementation showed improvements in mealtime positioning and assistance in all sites. Activity mapping in 85 patients before and 111 patients after implementation showed improvements in cognitive and social engagement in three sites, but inconsistent changes in mobility. The improvements in mealtime care and cognitive and social engagement are plausible mediators of reduced delirium observed in the trial. The lack of consistent mobility improvements may explain why the trial did not show reduction in functional decline.
Conclusions
A multi-level enabling facilitation approach supported adaptive implementation to varied contexts to support mechanisms of impact which partly achieved the programme goals. Contexts changed over time, suggesting the need for adequate time and continued facilitation to embed, enhance and sustain age-friendly practices on acute care wards and optimise outcomes.
Trial registration
The CHERISH trial was prospectively registered with the ANZCTR (http://www.anzctr.org.au): ACTRN12615000879561.
Background:
The increased complexity of residents and increased needs for care in long-term care (LTC) have not been met with increased staffing. There remains a need to improve the quality of care for residents. Care aides, providers of the bulk of direct care, are well placed to contribute to quality improvement efforts but are often excluded from so doing. This study examined the effect of a facilitation intervention enabling care aides to lead quality improvement efforts and improve the use of evidence-informed best practices. The eventual goal was to improve both the quality of care for older residents in LTC homes and the engagement and empowerment of care aides in leading quality improvement efforts.
Methods:
Intervention teams participated in a year-long facilitative intervention which supported care aide-led teams to test changes in care provision to residents using a combination of networking and QI education meetings, and quality advisor and senior leader support. This was a controlled trial with random selection of intervention clinical care units matched 1:1 post hoc with control units. The primary outcome, between group change in conceptual research use (CRU), was supplemented by secondary staff- and resident-level outcome measures. A power calculation based upon pilot data effect sizes resulted in a sample size of 25 intervention sites.
Results:
The final sample included 32 intervention care units matched to 32 units in the control group. In an adjusted model, there was no statistically significant difference between intervention and control units for CRU or in secondary staff outcomes. Compared to baseline, resident-adjusted pain scores were statistically significantly reduced (less pain) in the intervention group (p=0.02). The level of resident dependency significantly decreased statistically for residents whose teams addressed mobility (p<0.0001) compared to baseline.
Conclusions:
The Safer Care for Older Persons in (residential) Environments (SCOPE) intervention resulted in a smaller change in its primary outcome than initially expected resulting in a study underpowered to detect a difference. These findings should inform sample size calculations of future studies of this nature if using similar outcome measures. This study highlights the problem with measures drawn from current LTC databases to capture change in this population. Importantly, findings from the trial's concurrent process evaluation provide important insights into interpretation of main trial data, highlight the need for such evaluations of complex trials, and suggest the need to consider more broadly what constitutes "success" in complex interventions.
Trial registration:
ClinicalTrials.gov , NCT03426072, registered August 02, 2018, first participant site April, 05, 2018.
Background
Universal coverage of evidence-based interventions for perinatal health, often part of evidence-based guidelines, could prevent most perinatal deaths, particularly if entire communities were engaged in the implementation. Social innovations may provide creative solutions to the implementation of evidence-based guidelines, but successful use of social innovations relies on the engagement of communities and health system actors. This proof-of-concept study aimed to assess whether an earlier successful social innovation for improved neonatal survival that employed regular facilitated Plan-Do-Study-Act meetings on the commune level was feasible and acceptable when implemented on multiple levels of the health system (52 health units) and resulted in actions with plausibly favourable effects on perinatal health and survival in Cao Bang province, northern Vietnam.
Methods
The Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework guided the implementation and evaluation of the Perinatal Knowledge-Into-Practice (PeriKIP) project. Data collection included facilitators’ diaries, health workers’ knowledge on perinatal care, structured observations of antenatal care, focus group discussions with facilitators, their mentors and representatives of different actors of the initiated stakeholder groups and an individual interview with the Reproductive Health Centre director. Clinical experts assessed the relevance of the identified problems and actions taken based on facilitators’ diaries. Descriptive statistics included proportions, means, and t-tests for the knowledge assessment and observations. Qualitative data were analysed by content analysis.
Results
The social innovation resulted in the identification of about 500 relevant problems. Also, 75% of planned actions to overcome prioritised problems were undertaken, results presented and a plan for new actions to achieve the group’s goals to enhance perinatal health. The facilitators had significant roles, ensuring that the stakeholder groups were established based on principles of mutual respect. Overall, the knowledge of perinatal health and performance of antenatal care improved over the intervention period.
Conclusions
The establishment of facilitated local stakeholder groups can remedy the need for tailored interventions and grassroots involvement in perinatal health and provide a scalable structure for focused efforts to reduce preventable deaths and promote health and well-being.
Background
Clinical research coordinators (CRCs) facilitate the interaction between researchers and knowledge users in rehabilitation centres to promote and sustain evidence-informed practices. Despite their presence in rehabilitation settings in Quebec for over 20 years, little is known about their profiles and knowledge translation (KT) activities nor how they can best enact their role. This study explored CRCs’ roles and perspectives on the barriers, enablers, and strategies for improving KT activities in rehabilitation settings.
Methods
We conducted a multi-centre, participatory sequential mixed methods study. In the descriptive quantitative phase, we collected data via an online survey to determine CRCs’ role in research and KT. In the subsequent qualitative phase, we conducted an in-person focus group to elicit CRCs’ perspectives regarding factors influencing their work in KT, and potential solutions for overcoming these challenges. We used a descriptive and an inductive content analysis approach for the data analysis. The data synthesis was inspired by the Promoting Action on Research Implementation in Health Services framework.
Results
All nine CRCs from five partner health regions of a large rehabilitation research centre agreed to participate in the study. The data suggest that CRCs are like knowledge brokers and boundary spanners. As information managers, linkage agents and facilitators, CRCs play a pivot role in diffusion, dissemination, synthesis and tailoring of knowledge to improve evidence informed practices and quality of care in rehabilitation. The factors influencing CRCs’ KT activities are mostly linked to the context such as the receptivity of the organization as well as the lack of time and resources, and limited understanding of their roles by stakeholders. Two main suggestions made to enhance CRCs’ contribution to KT activities include the harmonisation of expectations between the large research centre and their partner health regions, and better promotion of their role to clinical and research teams.
Conclusions
This study provides valuable insights into the scope of CRCs’ role. The results shed light on the challenges that they face and potential solutions to overcome them. The knowledge generated in this study can be used to implement this role with similar duties in rehabilitation settings or other health care domains.
In this paper, we provide an overview of JBI's approach to evidence implementation and describe the supporting process model that aligns with this approach. The central tenets of JBI's approach to implementing evidence into practice include the use of evidence-based audit and feedback, identification of the context in which evidence is being implemented, facilitation of any change, and an evaluation process. A pragmatic and practical seven-phased approach is outlined to assist with the 'planning' and 'doing' of getting evidence into practice, focusing on clinicians as change agents for implementing evidence in clinical and policy settings. Further research and development is required to formally evaluate the robustness of the approach to better understand the complex nature of evidence implementation.
Background: Healthcare organizations have increasingly utilized facilitation to improve implementation of evidence-based practices and programs (e.g., primary care mental health integration). Facilitation is both a role, related to the purpose of facilitation, and a process, i.e., how a facilitator operationalizes the role. Scholars continue to call for a better understanding of this implementation strategy. Although facilitation is described as dynamic, activities are often framed within the context of a staged process. We explored two understudied characteristics of implementation facilitation: 1) how facilitation activities change over time and in response to context, and 2) how facilitators operationalize their role when the purpose of facilitation is both task-focused (i.e., to support implementation) and holistic (i.e., to build capacity for future implementation efforts.
Methods: We conducted individual monthly debriefings over thirty months with one external expert and two internal regional facilitators who were supporting PCMHI implementation in two VA networks. We developed a list of facilitation activities based on a literature review and debriefing notes. We coded what activities occurred and their intensity by quarter. We also coded whether facilitators were “doing” these activities for sites or “enabling” sites to perform them.
Results: Implementation facilitation activities did not occur according to a defined series of ordered steps but in response to specific organizational contexts through a non-linear and incremental process. Amount and types of activities varied between the networks. Concordant with facilitators’ planned role, the focus of some facilitation activities was primarily on doing them for the sites and others on enabling sites to do for themselves; a number of activities did not fit into one category and varied across networks.
Conclusions: Findings indicate that facilitation is a dynamic and fluid process, with facilitation activities, as well as their timing and intensity, occurring in response to specific organizational contexts. Understanding this process can help those planning and applying implementation facilitation to make conscious choices about the facilitation role on the doing/enabling continuum, and the activities that facilitators can use to operationalize this role. Additionally, this work provides the foundation from which future studies can identify potential mechanisms of action through which facilitation activities enhance implementation uptake.
The book was first published in 1994 and reprinted in 1994, 1995 (twice) and 1996 (twice).
To compare three approaches for marketing a quit smoking intervention kit to general practitioners.
Randomised trial of (a) personal delivery and presentation by an educational facilitator with a follow up visit six weeks later; (b) delivery to the receptionist by a friendly volunteer courier with a follow up phone call six weeks later, or (c) postal delivery with a follow up letter six weeks later.
Melbourne, Australia.
264 randomly selected general practitioners.
A research assistant visited each doctor four months after delivery and measured use of components of the kit. A questionnaire measuring perceptions of aspects of the kit and its delivery was completed by doctors. Costs of each approach were calculated.
Doctors receiving the educational facilitator approach were significantly more likely than those receiving the other two approaches to have seen the kit, to rate the method of delivery as engendering motivation to try the kit, to have used one of the "intensive intervention" components from the kit, to report that they found the kit less complicated, and to report greater knowledge of how to use the kit. There were no significant differences in use of "minimal intervention" components of the kit, ratings of overall acceptability of delivery, perceptions of cultural and structural barriers to using the kit, and ratings of the overall acceptability of the kit. The cost of the educational facilitator approach (A14) was twice the cost of the mailed approach.
Educational facilitators and volunteer couriers do not seem to be cost effective strategies for distributing smoking interventions.
A randomized controlled trial with 76 physicians in 16 community hospitals evaluated audit and feedback and local opinion leader education as methods of encouraging compliance with a guideline for the management of women with a previous cesarean section. The guideline recommended clinical actions to increase trial of labor and vaginal birth rates. Charts for all 3552 cases in the study groups were audited. After 24 months the trial of labor and vaginal birth rates in the audit and feedback group were no different from those in the control group, but rates were 46% and 85% higher, respectively, among physicians educated by an opinion leader. Duration of hospital stay was lower in the opinion leader education group than in the other two groups. The overall cesarean section rate was reduced only in the opinion leader education group. There were no adverse clinical outcomes attributable to the interventions. The use of opinion leaders improved the quality of care.
To review the literature relating to the effectiveness of education strategies designed to change physician performance and health care outcomes.
We searched MEDLINE, ERIC, NTIS, the Research and Development Resource Base in Continuing Medical Education, and other relevant data sources from 1975 to 1994, using continuing medical education (CME) and related terms as keywords. We manually searched journals and the bibliographies of other review articles and called on the opinions of recognized experts.
We reviewed studies that met the following criteria: randomized controlled trials of education strategies or interventions that objectively assessed physician performance and/or health care outcomes. These intervention strategies included (alone and in combination) educational materials, formal CME activities, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit with feedback, and reminders. Studies were selected only if more than 50% of the subjects were either practicing physicians or medical residents.
We extracted the specialty of the physicians targeted by the interventions and the clinical domain and setting of the trial. We also determined the details of the educational intervention, the extent to which needs or barriers to change had been ascertained prior to the intervention, and the main outcome measure(s).
We found 99 trials, containing 160 interventions, that met our criteria. Almost two thirds of the interventions (101 of 160) displayed an improvement in at least one major outcome measure: 70% demonstrated a change in physician performance, and 48% of interventions aimed at health care outcomes produced a positive change. Effective change strategies included reminders, patient-mediated interventions, outreach visits, opinion leaders, and multifaceted activities. Audit with feedback and educational materials were less effective, and formal CME conferences or activities, without enabling or practice-reinforcing strategies, had relatively little impact.
Widely used CME delivery methods such as conferences have little direct impact on improving professional practice. More effective methods such as systematic practice-based interventions and outreach visits are seldom used by CME providers.
The aim of this study was to determine the effectiveness and relative cost of three forms of information feedback to general practices--graphical, graphical plus a visit by a medical facilitator and tabular.
Routinely collected, centrally-held data were used where possible, analysed at practice level. Some non-routine practice data in the form of risk factor recording in medical notes, for example weight, smoking status, alcohol consumption and blood pressure, were also provided to those who requested it. The 52 participating practices were stratified and randomly allocated to one of the three feedback groups. The cost of providing each type of feedback was determined. The immediate response of practitioners to the form of feedback (acceptability), ease of understanding (intelligibility), and usefulness of regular feedback was recorded. Changes introduced as a result of feedback were assessed by questionnaire shortly after feedback, and 12 months later. Changes at the practice level in selected indicators were also assessed 12 and 24 months after initial feedback.
The resulting cost per effect was calculated to be 46.10 pounds for both graphical and tabular feedback, 132.50 pounds for graphical feedback plus facilitator visit and 773.00 pounds for the manual audit of risk factors recorded in the practice notes. The three forms of feedback did not differ in intelligibility or usefulness, but feedback plus a medical facilitator visit was significantly less acceptable. There was a high level of self-reported organizational change following feedback, with 69% of practices reporting changes as a direct result; this was not significantly different for the three types of feedback. There were no significant changes in the selected indicators at 12 or 24 months following feedback. The practice characteristic most closely related to better indicators of preventive practice was practice size, smaller practices performing significantly better. Separate clinics were not associated with better preventive practice.
It is concluded that feedback strategies using graphical and tabular comparative data are equally cost-effective in general practice with about two thirds of practices reporting organizational change as a consequence; feedback involving unsolicited medical facilitator visits is less cost-effective. The cost-effectiveness of manual risk factor audit is also called into question.
This paper has been written as a tool to help clinical physiotherapists to set up and run a problem-based continuing education programme for themselves and their colleagues in their work-place. The programme model is based on small group work, self-evaluation, self-initiated and self-directed learning, group learning and peer-group teaching and has been developed from the evaluations of innovatory CE programmes for therapists and general practitioners. This approach is designed to enable physiotherapists to take responsibility for their own education. It is suggested that the skills required for planning and implementing a problem-based initiative are already possessed by physiotherapists, and that these skills will be refined through the education process. The five stages of setting up and running a programme are described. A chick list and suggestions for further reading are presented for potential programme planners.
This paper describes the origin and history of problem-based learning in medical and physiotherapy education. The theoretical underpinnings of problem-based learning are presented, together with its relationship to patient treatment and evaluation of practice. Empirical evidence that suggests that this is an appropriate and effective approach for physiotherapy continuing education is discussed, with reference to evaluative and experimental research undertaken in this field. Although some questions remain unanswered, it is concluded that problem-based learning creates an environment in which desirable approaches to learning are adopted. An hypothesis is put forward to account for this. Finally, it is considered that problem-based learning can be a useful alternative approach for physiotherapy continuing education.
Objective.
—To determine whether brief, face-to-face educational outreach visits can improve the appropriateness of blood product utilization.
Design.
—Randomized, controlled multicenter trial with 6-month follow-up.
Setting.
—Surgical and medical services of two pairs of matched community and teaching hospitals in Massachusetts.
Participants.
—One hundred one transfusing staff surgeons and attending medical physicians.
Intervention.
—A professionally based transfusion specialist presented one surgical- or medical-service—wide lecture emphasizing appropriate indications, risks, and benefits of red blood cell transfusions; brief, graphic, printed educational guidelines; and one 30-minute visit with each transfusing physician. No data feedback was provided. Educational messages emphasized the lack of utility of the traditional threshold for red blood cell transfusions (hematocrit, 30%) and transfusion risks (eg, viral hepatitis).
Measures.
—Proportion of red blood cell transfusions classified as compliant or noncompliant with blood transfusion guidelines, or indeterminate 6 months before and 6 months after an experimental educational intervention.
Results.
—Based on analyses of 1449 medical record audits of red blood cell transfusions that occurred 6 months before and 6 months after the educational intervention, the average proportion of transfusions not in compliance with criteria declined from 0.40 to 0.24 among study surgeons (-40%) compared with an increase from 0.40 to 0.44 (+9%) among control surgeons (P=.006). These effects were consistent across procedure type and specialty. On average, study surgeons in the postintervention period performed transfusions when hematocrits were 2.0 percentage points lower than before the intervention (28.3% preintervention vs 26.3% postintervention), and lower than in the control group (28.3% preintervention and postintervention; P=.04). Likely savings in blood use for surgical services probably exceeded program costs, even without considering reduced risks of infection. No effects were observed among transfusions occurring in medical services, possibly because of substantially lower transfusion rates and lower pretransfusion hematocrits.
Conclusions.
—Brief, focused educational outreach visits by transfusion specialists can substantially improve the appropriateness and cost-effectiveness of blood product use in surgery. More data are needed regarding the durability of changes in practice patterns and the health and economic benefits of such interventions.(JAMA. 1993;270:961-966)
Objective.
—To review the literature relating to the effectiveness of education strategies designed to change physician performance and health care outcomes.Data Sources.
—We searched MEDLINE, ERIC, NTIS, the Research and Development Resource Base in Continuing Medical Education, and other relevant data sources from 1975 to 1994, using continuing medical education (CME) and related terms as keywords. We manually searched journals and the bibliographies of other review articles and called on the opinions of recognized experts.Study Selection.
—We reviewed studies that met the following criteria: randomized controlled trials of education strategies or interventions that objectively assessed physician performance and/or health care outcomes. These intervention strategies included (alone and in combination) educational materials, formal CME activities, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit with feedback, and reminders. Studies were selected only if more than 50% of the subjects were either practicing physicians or medical residents.Data Extraction.
—We extracted the specialty of the physicians targeted by the interventions and the clinical domain and setting of the trial. We also determined the details of the educational intervention, the extent to which needs or barriers to change had been ascertained prior to the intervention, and the main outcome measure(s).Data Synthesis.
—We found 99 trials, containing 160 interventions, that met our criteria. Almost two thirds of the interventions (101 of 160) displayed an improvement in at least one major outcome measure: 70% demonstrated a change in physician performance, and 48% of interventions aimed at health care outcomes produced a positive change. Effective change strategies included reminders, patient-mediated interventions, outreach visits, opinion leaders, and multifaceted activities. Audit with feedback and educational materials were less effective, and formal CME conferences or activities, without enabling or practice-reinforcing strategies, had relatively little impact.Conclusion.
—Widely used CME delivery methods such as conferences have little direct impact on improving professional practice. More effective methods such as systematic practice-based interventions and outreach visits are seldom used by CME providers.(JAMA. 1995;274:700-705)
In Reply.
—Dr Ellerbeck suggests that only the opinion leaders generated the changes seen in the OLE group and, in any event, the information provided to the OLE group may have improved compliance without the use of opinion leaders. Both are potentially valid criticisms of opinion leader strategies; neither, however, appears to apply to this study.The opinion leaders managed only 30.4% of the eligible cases and, as stated in the article, "in no community did the opinion leader have the highest compliance rates." If the opinion leaders are removed from the analysis, the trial of labor and vaginal birth rates in the OLE group are, respectively, 33.1% and 21.6%—clearly, therefore, a community-wide phenomenon.The design of the OLE intervention was based on existing research demonstrating that the isolated provision of even nontraditional educational material fails to improve practice.1-3 We see no reason why our study would have been
Continuous quality improvement has resulted in the need for the development of new and exciting skills in group dynamics and in the facilitation of small group interactions. Leaders of quality work groups must use the understanding of group dynamics and leadership to maintain high performance work teams. To be effective, the team leaders and members must be aware of what is being said (content) and how things are being said (processes). Team leaders and groups can not be guaranteed effectiveness. However, development of the necessary skills in team building will ensure the likelihood of effective group processes and positive outcomes.
• The paper describes a multiproject practice development programme undertaken over a period of 1 year.
• The background and development of the programme are outlined, whilst attention is paid to the innovatory nature of the work, particularly the use of inductive, deductive and integrated approaches to both change implementation and project supervision.
• The programme was monitored throughout using different data sources and the paper uses evaluative material retrospectively to provide answers to organizational and professional difficulties which arose during the course of the programme.
• The authors conclude that the use of combinations of different models for practice development has potential, but requires careful supervision.
• They also recommend that those involved in practice development are made fully aware of its local or micropolitics, and develop strategies to deal with change before it occurs, not after it has taken place.
The term 'practice development' is widely but inconsistently used in British nursing, addressing a broad range of educational, research, and audit activity, but there appears to be little consensus as to what practice development actually involves. Such lack of clarity means that the increasing number of nurses whose work involves addressing practice development issues can have difficulty in focusing their efforts.
To try to clarify the concept of practice development and to describe the focuses of practice development work and the approaches used, a concept analysis was conducted. Both primary and secondary data were gathered and analysed in the study. One hundred and seventy seven items of published literature were gathered and analysed. Focus group interviews were carried out involving 60 practice developers. In addition, 25 clinical nurses were interviewed about their experiences of being involved in practice development.
This paper describes the identified purposes, attributes and outcomes of practice development. Practice development activities are described as addressing the effectiveness of care through the transformation of care practices and cultures. Practice development is described as a systematic, rigorous activity underpinned by facilitation processes. The outcomes of practice development can be described in terms of changes in the behaviours, values and beliefs of staff involved. Parallels between practice development and current policy imperatives are outlined.
This paper presents the results of a one-year practice development project undertaken in a rehabilitation ward for older people with the intention of developing the quality of rehabilitation practice and of exploring the potential for nurses to work as case managers.
The baseline data showed that the culture of the ward reflected a custodial approach to patient care, a lack of effective clinical leadership and poor understanding of the rehabilitation needs of older people. It was concluded that changes to practice were needed before a case management approach to care could be considered. A systematic practice development approach was adopted, incorporating pre- and post-development evaluation methods. A comparison ward was used to compare the impact on clinical practice of the change strategies used.
The ensuing development strategy focused on facilitating nurses and other members of the multidisciplinary team to question their own attitudes, beliefs and values and to begin to challenge clinical practice. Ongoing work was aimed at implementing cultural and structural changes agreed by the multidisciplinary team, supported by research evidence, in order to establish new norms of clinical practice and leadership. As a result of the project, the ward team was in a much better position to develop a case management approach to patient care, and to implement the development needs identified within the post-evaluation data.
Describes the job of a facilitator in a quality of work life (QWL) program. The facilitator's primary duty is to develop team dynamics by improving group processes and avoiding active involvement in the content of the team's efforts. Facilitators may not be popular with their groups since part of their job is to point out conflict and describe observed behaviors. Facilitators should become figures of empowerment for QWL teams by encouraging team members to explore new ways of thinking and new sources of information. Such work may include interceding with union representatives and with managers. (1 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This is the seventh in a series of eight articles analysing the gap between research and practiceSeries editors: Andrew Haines and Anna DonaldDespite the considerable amount of money spent on clinical research relatively little attention has been paid to ensuring that the findings of research are implemented in routine clinical practice.1 There are many different types of intervention that can be used to promote behavioural change among healthcare professionals and the implementation of research findings. Disentangling the effects of intervention from the influence of contextual factors is difficult when interpreting the results of individual trials of behavioural change.2 Nevertheless, systematic reviews of rigorous studies provide the best evidence of the effectiveness of different strategies for promoting behavioural change. 3 4 In this paper we examine systematic reviews of different strategies for the dissemination and implementation of research findings to identify evidence of the effectiveness of different strategies and to assess the quality of the systematic reviews.
Summary points
Systematic reviews of rigorous studies provide the best evidence on the effectiveness of different strategies to promote the implementation of research findings
Passive dissemination of information is generally ineffective
It seems necessary to use specific strategies to encourage implementation of research based recommendations and to ensure changes in practice
Further research on the relative effectiveness and efficiency of different strategies is required
Identification and inclusion of systematicreviews
We searched Medline records dating from 1966 to June 1995 using a strategy developed in collaboration with the NHS Centre for Reviews and Dissemination. The search identified 1139 references. No reviews from the Cochrane Effective Practice and Organisation of Care Review Group4 had been published during this time. In addition, we searched the Database of Abstracts of Research Effectiveness (DARE) (http://www.york.ac.uk/inst/crd) but did not identify any other review meeting the inclusion criteria.
We searched for any review …
In this paper a case study is used to explore critically the complexities of caring that faced one of us, K.B., as a relatively inexperienced primary nurse, in working with a ‘respite‐care’ family to achieve effective care.
The medium of reflection and supervision is used to describe this experience and the emerging issues.
Through the use of reflection, Kate was able to unravel the complexities of caring and learn to work therapeutically with this family.
Aims This analysis sets out to explore the nature and scope of the concept of practice development.
Background The last 10 years has seen a growing interest in the development of health care practice. However, the exact nature of practice development remains poorly articulated and nebulous. Literature from nursing, medical, accountancy, social work and counselling is used to identify the critical attributes of the concept.
Data analysis The analysis uses the techniques developed by Walker & Avant (1995) to collect information on the use of the concept from the literature and to construct cases.
Key issues Many of the attributes of practice development are shared by other related concepts such as innovation. However, four critical attributes of practice development were identified and illustrated through case construction.
Conclusions An understanding of the nature and scope of practice development is essential if the role of the Practice Development Nurse is to be evaluated. The critical attributes and empirical referents identified in this analysis provide a framework for both role development and evaluation.
Research information in nurses’ clinical decision‐making: what is useful?
Aim. To examine those sources of information which nurses find useful for reducing the uncertainty associated with their clinical decisions.
Background. Nursing research has concentrated almost exclusively on the concept of research implementation. Few, if any, papers examine the use of research knowledge in the context of clinical decision‐making. There is a need to establish how useful nurses perceive information sources are, for reducing the uncertainties they face when making clinical decisions.
Design. Cross‐case analysis involving qualitative interviews, observation, documentary audit and Q methodological modelling of shared subjectivities amongst nurses. The case sites were three large acute hospitals in the north of England, United Kingdom. One hundred and eight nurses were interviewed, 61 of whom were also observed for a total of 180 hours and 122 nurses were involved in the Q modelling exercise.
Results. Text‐based and electronic sources of research‐based information yielded only small amounts of utility for practising clinicians. Despite isolating four significantly different perspectives on what sources were useful for clinical decision‐making, it was human sources of information for practice that were overwhelmingly perceived as the most useful in reducing the clinical uncertainties of nurse decision‐makers.
Conclusions. It is not research knowledge per se that carries little weight in the clinical decisions of nurses, but rather the medium through which it is delivered. Specifically, text‐based and electronic resources are not viewed as useful by nurses engaged in making decisions in real time, in real practice, but those individuals who represent a trusted and clinically credible source are. More research needs to be carried out on the qualities of people regarded as clinically important information agents (specifically, those in clinical nurse specialist and associated roles) whose messages for practice appear so useful for clinicians.
In the National Health Service clinical audit is gradually evolving into a broader quality assurance programme for all health professionals. However, members of primary health care teams need support if they are to collaborate effectively to develop quality assurance. In this paper a number of relevant lessons are discussed which have been highlighted by the experiences of two studies of facilitation of multiprofessional clinical audit in primary health care.
We believe that many general practitioners would practice preventive medicine if they had the opportunity to organise their practice to do this. We therefore provided a "facilitator," who understands the work of a general practice, to help practices that were interested in prevention to set up programmes. She, for example, helped the primary care team to set up objectives, trained practice nurses to measure blood pressure, and set up a system to measure the progress of the programme.
To test the impact of physician education and facilitator assisted office system interventions on cancer early detection and preventive services.
A randomised trial of two interventions alone and in combination.
Physicians in 98 ambulatory care practices in the United States.
The education intervention consisted of a day long physician meeting directed at improving knowledge, attitudes, and skills relevant to cancer prevention and early detection. The office system intervention consisted of assistance from a project facilitator in establishing routines for providing needed services. These routines included division of responsibilities for providing services among physicians and their staff and the use of medical record flow sheets.
The proportions of patients provided the cancer prevention and early detection services indicated annually according to the US National Cancer Institute.
Based on cross sectional patient surveys, the office system intervention was associated with an increase in mammography, the recommendation to do breast self examination, clinical breast examination, faecal occult blood testing, advice to quit smoking, and the recommendation to decrease dietary fat. Education was associated only with an increase in mammography. Record review for a patient cohort confirmed cross sectional survey findings regarding the office system for mammography and faecal occult blood testing.
Community practices assisted by a facilitator in the development and implementation of an office system can substantially improve provision of cancer early detection and preventive services.
To the Editor.
—Lomas et al1 looked at two different methods of changing medical practices that had not been influenced by explicit practice guidelines. In this innovative study, the authors found that physicians in hospitals receiving an opinion leader education (OLE) intervention were less likely to perform inappropriate cesarean sections than physicians in control hospitals and hospitals receiving audit and feedback. Two aspects of the design and analysis of this study, however, make it difficult to determine whether or not the better compliance with cesarean section guidelines in the OLE group was actually due to the influence of the opinion leader on his or her fellow physicians.First, the higher compliance with cesarean section guidelines in the OLE group may have been due to the practices of the opinion leaders themselves. The four opinion leaders received 1½ days of intense training in the guidelines for performance of cesarean sections;
This paper charts the progress of an action research project initially implemented to assist the staff of a pediatric ward in the development of primary nursing. The use of ward meetings to identify needs and clarify objectives is discussed; from this emerged a broader remit to implement the ward's philosophy of care. Five areas of clinical practice development were identified for work: development of a staff development strategy, identification of resource people, movement to primary nursing, development of standards of care, and development of the ward environment. Progress in these five areas is explored, and the use of evaluation strategies such as visual analogue scales, unstructured interviews and personal diaries are discussed. Description and discussion of some of the difficulties associated with this project are given. In conclusion, the authors address the issue of whether action research is in fact a specific methodology or a philosophy.
A study is described in which three general practices were provided with low cost, low technology support from a "facilitator" and were compared with control practices in the ascertainment of major risk factors for cardiovascular disease in middle aged patients. Patients who were attending for a consultation with their general practitioners were recruited to make an appointment with a practice nurse for a health check, and this was compared with ordinary consultations in the control practices. Practices were helped by the facilitator to develop the nurse's role. During the study the increase between intervention and control practices in blood pressure recording was doubled and in the recording of smoking habit it was quadrupled, and there was a fivefold increase in the recording of weight. This model can be applied to other aspects of prevention and general practice care.
A task force is a technique that can be used by the dietitian-manager to develop solutions for specific, identified problems. Because employees are directly involved in the decision-making process, better solutions--ones that are also more acceptable to the work group--result. To implement a task force, management must plan the strategy: Select a facilitator, explain the concept and problem to the work group, select task force participants, and make meeting arrangements. The task force meetings should be structured to maximize efficiency and productivity. The plan of action is developed by the task force members; all decisions are based upon input from the work group. Successful implementation of the solutions is the responsibility of the task force. Applications for task forces in both the clinical and food management areas are numerous and result in both tangible and intangible benefits.
Improving precision and economy in the prescribing of drugs is a goal whose importance has increased with the proliferation of new and potent agents and with growing economic pressures to contain health-care costs. We implemented an office-based physician education program to reduce the excessive use of three drug groups: cerebral and peripheral vasodilators, an oral cephalosporin, and propoxyphene. A four-state sample of 435 prescribers of these drugs was identified through Medicaid records and randomly assigned to one of three groups. Physicians who were offered personal educational visits by clinical pharmacists along with a series of mailed "unadvertisements" reduced their prescribing of the target drugs by 14 per cent as compared with controls (P = 0.0001). A comparable reduction in the number of dollars reimbursed for these drugs was also seen between the two groups, resulting in substantial cost savings. No such change was seen in physicians who received mailed print materials only. The effect persisted for at least nine months after the start of the intervention, and no significant increase in the use of expensive substitute drugs was found. Academically based "detailing" may represent a useful and cost-effective way to improve the quality of drug-therapy decisions and reduce unnecessary expenditures.
We believe that many general practitioners would practice preventive medicine if they had the opportunity to organise their practice to do this. We therefore provided a "facilitator," who understands the work of a general practice, to help practices that were interested in prevention to set up programmes. She, for example, helped the primary care team to set up objectives, trained practice nurses to measure blood pressure, and set up a system to measure the progress of the programme.
In this article, the traditional methods of concept development are critiqued, and alternative methods that use qualitative methods of inquiry are presented. Variations of concept development techniques appropriate to the maturity of the concept being explored are then described, including methods for concept delineation, concept comparison, concept clarification, concept correction, and concept identification. To illustrate the application of concept development methods to nursing theory, a research program to delineate the construct of comfort is described.
This 1‐year study tested the transferability of the Primary Care Facilitator model to the hospital setting, and was designed to assess and enhance existing hospital health‐promotion activity.
From work with nurses on three wards in an acute general hospital, the Primary Health Care model was found to be appropriate for the hospital setting.
There were demonstrable changes in attitudes to health promotion and an increase in health‐promotion activity. It now appears appropriate to evaluate the role of the hospital health‐promotion facilitator on a wider basis.
Areas for further research, beyond the scope of this particular project, should be the quality of the health‐promotion activity and exploration of factors that encourage or inhibit utilization of health‐promotion opportunities.
Continuous quality improvement has resulted in the need for the development of new and exciting skills in group dynamics and in the facilitation of small group interactions. Leaders of quality work groups must use the understanding of group dynamics and leadership to maintain high performance work teams. To be effective, the team leaders and members must be aware of what is being said (content) and how things are being said (processes). Team leaders and groups can not be guaranteed effectiveness. However, development of the necessary skills in team building will ensure the likelihood of effective group processes and positive outcomes.
To determine whether brief, face-to-face educational outreach visits can improve the appropriateness of blood product utilization.
Randomized, controlled multicenter trial with 6-month follow-up.
Surgical and medical services of two pairs of matched community and teaching hospitals in Massachusetts.
One hundred one transfusing staff surgeons and attending medical physicians.
A professionally based transfusion specialist presented one surgical- or medical-service-wide lecture emphasizing appropriate indications, risks, and benefits of red blood cell transfusions; brief, graphic, printed educational guidelines; and one 30-minute visit with each transfusing physician. No data feedback was provided. Educational messages emphasized the lack of utility of the traditional threshold for red blood cell transfusions (hematocrit, 30%) and transfusion risks (eg, viral hepatitis).
Proportion of red blood cell transfusions classified as compliant or noncompliant with blood transfusion guidelines, or indeterminate 6 months before and 6 months after an experimental educational intervention.
Based on analyses of 1449 medical record audits of red blood cell transfusions that occurred 6 months before and 6 months after the educational intervention, the average proportion of transfusions not in compliance with criteria declined from 0.40 to 0.24 among study surgeons (-40%) compared with an increase from 0.40 to 0.44 (+9%) among control surgeons (P = .006). These effects were consistent across procedure type and specialty. On average, study surgeons in the postintervention period performed transfusions when hematocrits were 2.0 percentage points lower than before the intervention (28.3% preintervention vs 26.3% postintervention), and lower than in the control group (28.3% preintervention and postintervention; P = .04). Likely savings in blood use for surgical services probably exceeded program costs, even without considering reduced risks of infection. No effects were observed among transfusions occurring in medical services, possibly because of substantially lower transfusion rates and lower pretransfusion hematocrits.
Brief, focused educational outreach visits by transfusion specialists can substantially improve the appropriateness and cost-effectiveness of blood product use in surgery. More data are needed regarding the durability of changes in practice patterns and the health and economic benefits of such interventions.
To describe the impact of the 'facilitator model' of promotion on two Australian general practices.
Attitudes and health promotion levels were evaluated before and after the facilitator worked with two practices.
Simple changes to patient records were the most successful.
Facilitators are acceptable and long term organisational changes can be achieved.
Quality, audit and standard setting are major issues on the present day nursing and health care agenda. Considerable time, energy and resources have been invested in developing and implementing a range of different quality and audit systems, yet there is limited evidence to date to suggest that they are having any significant impact in terms of changing practice and improving patient care. This paper will present the results of a study undertaken to evaluate the implementation of three of the most common nursing quality systems used in the United Kingdom: Monitor, Qualpacs and the dynamic standard setting system (DySSSy). In each case, the focus was on identifying key factors in the process of implementation that could predict positive programme outcomes--defined in terms of acceptance by clinical nursing staff and perceived impact on the quality of patient care. The study adopted a three-stage evaluation design, with three distinct levels of investigation and analysis, and utilized a range of descriptive and exploratory methods. In total, 14 sites implementing one of the three nursing quality systems were studied. Additional data, derived from individuals' experiences of implementing quality in nursing, were used to enhance and validate the findings. The results indicated a number of important system-related, contextual and practical issues of implementation. These were underpinned by two key factors, defined as ownership for quality and action to improve. However, most present day nursing quality programmes appear to be failing to embrace these two concepts simultaneously. The paper will conclude by discussing the implications of these findings for future developments in nursing and health care quality improvement.