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Getting evidence into practice: The role and function of facilitation

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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.

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... For example, the Promoting Action on Research Implementation in Health Services (PARiHS) framework presents successful implementation research as a function of the relationship between evidence, context, and facilitation [8]. Change facilitation has become a key component in supporting teams during the implementation of change in practice [9] and has proven effective across a variety of healthcare settings [10]. A change facilitator can provide support to stakeholders to 'realise what they need to change and how to make changes to incorporate evidence into practice' [11]. ...
... Implementation barriers were coded using a pre-defined list based on the CFIR [22], TICD [23] and TDF [22] (Additional file 1). Facilitation strategies were mapped according to those identified from two systematic reviews [9,26] (Additional file 2). One systematic review looked at facilitation strategies conducted in nursing, from which the Taxonomy of Facilitation Strategies was developed [9], and the second systematic review identified facilitation strategies recorded in randomized controlled trials focusing on the implementation of innovation in healthcare [26]. ...
... Facilitation strategies were mapped according to those identified from two systematic reviews [9,26] (Additional file 2). One systematic review looked at facilitation strategies conducted in nursing, from which the Taxonomy of Facilitation Strategies was developed [9], and the second systematic review identified facilitation strategies recorded in randomized controlled trials focusing on the implementation of innovation in healthcare [26]. ...
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Background Implementation research has delved into barriers to implementing change and interventions for the implementation of innovation in practice. There remains a gap, however, that fails to connect implementation barriers to the most effective implementation strategies and provide a more tailored approach during implementation. This study aimed to explore barriers for the implementation of professional services in community pharmacies and to predict the effectiveness of facilitation strategies to overcome implementation barriers using machine learning techniques. Methods Six change facilitators facilitated a 2-year change programme aimed at implementing professional services across community pharmacies in Australia. A mixed methods approach was used where barriers were identified by change facilitators during the implementation study. Change facilitators trialled and recorded tailored facilitation strategies delivered to overcome identified barriers. Barriers were coded according to implementation factors derived from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Tailored facilitation strategies were coded into 16 facilitation categories. To predict the effectiveness of these strategies, data mining with random forest was used to provide the highest level of accuracy. A predictive resolution percentage was established for each implementation strategy in relation to the barriers that were resolved by that particular strategy. Results During the 2-year programme, 1131 barriers and facilitation strategies were recorded by change facilitators. The most frequently identified barriers were a ‘lack of ability to plan for change’, ‘lack of internal supporters for the change’, ‘lack of knowledge and experience’, ‘lack of monitoring and feedback’, ‘lack of individual alignment with the change’, ‘undefined change objectives’, ‘lack of objective feedback’ and ‘lack of time’. The random forest algorithm used was able to provide 96.9% prediction accuracy. The strategy category with the highest predicted resolution rate across the most number of implementation barriers was ‘to empower stakeholders to develop objectives and solve problems’. Conclusions Results from this study have provided a better understanding of implementation barriers in community pharmacy and how data-driven approaches can be used to predict the effectiveness of facilitation strategies to overcome implementation barriers. Tailored facilitation strategies such as these can increase the rate of real-time implementation of innovations in healthcare, leading to an industry that can confidently and efficiently adapt to continuous change.
... This framework presents successful implementation research as a function of the relationship between evidence, context and facilitation [7]. Of the three, 'facilitation' has been proposed as a key role which not only affects the context in which change is taking place, but also aids participants in making sense of the evidence being implemented [8]. Utilising a 'change facilitator' (CF) has become a key component in supporting teams during the implementation of change in practice [8]. ...
... Of the three, 'facilitation' has been proposed as a key role which not only affects the context in which change is taking place, but also aids participants in making sense of the evidence being implemented [8]. Utilising a 'change facilitator' (CF) has become a key component in supporting teams during the implementation of change in practice [8]. A CF can provide support to stakeholders to "realise what they need to change and how to make changes to incorporate [professional service] evidence into practice" [9]. ...
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Background: Implementation research has delved into barriers to implementing change and interventions for the implementation of innovation in practice. There remains a gap, however, that fails to connect implementation barriers to the most effective strategies and provide more tailored interventions during implementation. This study aimed to link implementation barriers to facilitation strategies during a study in community pharmacy and use a data-driven approach to predict the level of effectiveness of facilitation strategies to overcome these barriers. Methods: Six Change facilitators facilitated a two-year change program aimed at implementing professional services across 19 community pharmacies across Australia. A mixed method approach was used where barriers were identified and coded according to implementation factors from the Consolidated Framework of Implementation Research, the Theoretical Domains Framework and the Integrated Checklist of Determinants of practice. Change facilitators trialled and recorded different facilitation strategies to overcome these barriers, until the barrier was resolved. To predict the effectiveness of these strategies a data mining approach named Random Forest was used to provide the highest level of accuracy. Results: At the end of the program, 1,131 data points were recorded by change facilitators. Upon analysis, 36 barriers were identified. The most frequently identified barrier was a ‘lack of ability to plan for change’ (n=184). A list of 111 change facilitation strategies were extracted from the data. These were coded into 16 facilitation categories according to the Taxonomy of Facilitation Strategies. The most effective strategy category to overcome an ‘inability to plan for change’ was to ‘engage stakeholders by creating ownership’ which had a Predictive Resolution Percentage of 84%. Conclusions: Results from this study have provided a better understanding of implementation barriers in community pharmacy and a data-driven approach to predict the effectiveness of facilitation strategies to overcome these barriers. Tailored facilitation strategies may increase the rate of implementation of innovations in healthcare, leading to an industry that can confidently adapt to continuous change.
... Reilly (2008) details the competencies required of the facilitator: knowledge about personality, group dynamics, interpersonal skills such as listening and diagnosing, personal self-awareness of values and ethical frameworks, and personal qualities including empathy and caring. Harvey et al. (2002) add the traits of pragmatism, risk taking, communication skills, patience and commitment. Another interpersonal dimension of the facilitator's expertise involves identifying problems related to the group's growth and to participants' development (Reilly 2008). ...
... A summary of these theoretical threads points to the conclusion that research on teacher PLCs describes facilitator's activities while less emphasis has been devoted to the characteristics of the verbal-interaction taking place in these frameworks. Facilitators' organisational activities, expertise, and approaches are core elements in PLCs, but their facilitation actually refers to the process of promoting and enabling learning among individuals and groups (Harvey et al. 2002). Few studies have addressed these aspects. ...
Article
This qualitative study focuses on characteristics of interactions taking place within facilitation activities in teacher educators' learning communities. Although facilitators are perceived to hold a key role in professional learning, there is sparse literature analysing their functioning for learning in the communal context. Data include transcriptions from seven yearlong professional learning communities. An analysis of discourse was used to explore facilitation activities in teacher educators’ learning communities. The analysis revealed two themes with several categories. Promoting critical thinking included, identifying meaningful patterns, thinking representations focused on identification, understanding, and constructing meaning, promoting reflection and promoting alternate perspectives and redefinitions. The theme of offering direction included elaboration, modelling, and taking the role of the learner. The study suggests the importance of the facilitator’s positioning within the professional learning community and offers a research model for examining facilitator-participant interaction, recognizing the significance of this function for teacher educators’ professional learning. It also supports facilitators’ planning and execution of professional learning processes.
... Facilitators and others in similar roles, e.g., knowledge brokers [25], learn about how to support implementation through formal training programs that use didactics [26,27] and/or participatory methods [28][29][30][31] in short, time-limited workshops [32] or multiple workshops [26,[29][30][31]33]; on-the-job training; ongoing mentoring [3]; or a combination of workshops(s) and mentoring [26,30,34]. They may learn through publicly available materials [26,35,36] and/or through experience by trial and error [37]. Learning about implementation facilitation and the activities facilitators perform is necessary but not sufficient for developing these complex skills. ...
... We conducted this study within the context of a large Department of Veterans Affairs (VA) funded project that applied a facilitation strategy to support implementation of evidence-based primary care mental health integration (PCMHI) care models in eight VA primary care clinics. The original PARIHS framework informed the design of our facilitation strategy, a blend of external and internal facilitation [37,52]. We tested the strategy by comparing outcomes to eight clinics that did not receive facilitation [3,4]. ...
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Background There is substantial evidence that facilitation can address the challenges of implementing evidence-based innovations. However, facilitators need a wide variety of complex skills; lack of these can have a negative effect on implementation outcomes. Literature suggests that novice and less experienced facilitators need ongoing support from experts to develop these skills. Yet, no studies have investigated the transfer process. During a test of a facilitation strategy applied at 8 VA primary care clinics, we explored the techniques and processes an expert external facilitator utilized to transfer her skills to two initially novice internal facilitators who became experts. Methods In this qualitative descriptive study, we conducted monthly debriefings with three facilitators over a 30-month period and documented these in detailed notes. Debriefings with the expert facilitator focused on how she trained and mentored facilitation trainees. We also conducted, recorded, and transcribed two semi-structured qualitative interviews with each facilitator and queried them about training content and process. We used a mix of inductive and deductive approaches to analyze data; our analysis was informed by a review of mentoring, coaching, and cognitive apprenticeship literature. We also used a case comparison approach to explore how the expert tailored her efforts. Results The expert utilized 21 techniques to transfer implementation facilitation skills. Techniques included both active (providing information, modeling, and coaching) and participatory ones. She also used techniques to support learning, i.e., cognitive supports (making thinking visible, using heuristics, sharing experiences), psychosocial supports, strategies to promote self-learning, and structural supports. Additionally, she transferred responsibility for facilitation through a dynamic process of interaction with trainees and site stakeholders. Finally, the expert varied the level of focus on particular skills to tailor her efforts to trainee and local context. Conclusions This study viewed the journey from novice to expert facilitator through the lens of the expert who transferred facilitation skills to support implementation of an evidence-based program. It identified techniques and processes that may foster transfer of these skills and build organizational capacity for future implementation efforts. As the first study to document the implementation facilitation skills transfer process, findings have research and practical implications.
... One strategy that has been examined to implement PS services in mental health settings is external facilitation [19]. External facilitation is an evidencebased implementation strategy specified within the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework [28][29][30][31][32], in which outside individuals activate and support implementation by assessing and responding to characteristics of recipients of the innovation, taking into consideration additional factors within their inner organizational and outer contextual settings [28]. It is a multifaceted strategy involving interactive problem-solving and support that occurs in a context of a recognized need for improvement and supportive interpersonal relationships [33]. ...
... As is typical for external facilitation, facilitators engaged in multiple proactive strategies, tailored to each location [46]. These activities are summarized in Table 1 [29,42,[46][47][48]. ...
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Background Over 1100 veterans work in the Veterans Health Administration (VHA) as peer specialists (PSs)—those with formal training who support other veterans with similar diagnoses. A White House Executive Action mandated the pilot reassignment of VHA PSs from their usual placement in mental health to 25 primary care Patient Aligned Care Teams (PACTs) in order to broaden the provision of wellness services that can address many chronic illnesses. An evaluation of this initiative was undertaken to assess the impact of outside assistance on the deployment of PSs in PACTs, as implementation support is often needed to prevent challenges commonly experienced when first deploying PSs in new settings. Methods This study was a cluster-randomized hybrid II effectiveness-implementation trial to test the impact of minimal implementation support vs. facilitated implementation on the deployment of VHA PSs in PACT over 2 years. Twenty-five Veterans Affairs Medical Centers (VAMCs) were recruited to reassign mental health PSs to provide wellness-oriented care in PACT. Sites in three successive cohorts ( n = 7, 10, 8) over 6-month blocks were matched and randomized to each study condition. In facilitated implementation, an outside expert worked with site stakeholders through a site visit and regular calls, and provided performance data to guide the planning and address challenges. Minimal implementation sites received a webinar and access to the VHA Office of Mental Health Services work group. The two conditions were compared on PS workload data and veteran measures of activation, satisfaction, and functioning. Qualitative interviews collected information on perceived usefulness of the PS services. Results In the first year, sites that received facilitation had higher numbers of unique veterans served and a higher number of PS visits, although the groups did not differ after the second year. Also, sites receiving external facilitation started delivering PS services more quickly than minimal support sites. All sites in the external facilitation condition continued in the pilot into the second year, whereas two of the sites in the minimal assistance condition dropped out after the first year. There were no differences between groups on veterans’ outcomes—activation, satisfaction, and functioning. Most veterans were very positive about the help they received as evidenced in the qualitative interviews. Discussion These findings demonstrate that external facilitation can be effective in supporting the implementation of PSs in primary care settings. The lack of significant differences across conditions after the second year highlights the positive outcomes associated with active facilitation, while also raising the important question of whether longer-term success may require some level of ongoing facilitation and implementation support. Trial registration This project is registered at ClinicalTrials.gov with number NCT02732600 (URL: https://clinicaltrials.gov/ct2/show/NCT02732600 ).
... These characteristics are specific to cases and purposes and can be captured through actor analysis (Reed et al., 2009). Facilitators mediate structured or unstructured information elicitation as well as individual and collective learning through a computer-supported environment (Clawson, Bostrom, & Anson, 1993;Harvey et al., 2002). There are more informal roles, e.g., networker, honest broker, change agent, and epistemediator, who can serve as important procedural levers (Brundiers, Wiek, & Kay, 2013). ...
... As each event should produce results to serve the overall purpose, there needs to be a degree of interaction with the participants, an adequate mechanism for this interaction, the intention of the event(s), and subsequently the appropriate method of engagement to allow staff and the research team to adapt their respective roles (c.f. Harvey et al., 2002;Stauffacher et al., 2008). Regarding the content, a precise joint problem definition, interpretation, and development of shared terms and language needs to be coordinated between actors, including an introductory package to enable the participants to understand the event and the entire place and mode of work. ...
Article
Semi-immersive visualization facilities support research, planning, and decision-making at the science-society-policy interface. Decision theaters, visualization studios, and similar installations—here referred to as Decision-Visualization Environments (DVEs)—facilitate human-computer-content interactions to explore climate change impacts, resource management practices, and urban design solutions. This comparative study analyzes the current practices of seven DVE facilities from around the world based on expert interviews, site visits, and document review. We found common practices across 53 attributes concerning the planning, stakeholder involvement, and realization of DVE activities. DVEs need good facilitation and purposeful combination to unlock their full potential. An active network of DVEs could constitute a productive learning community to pool and coordinate activities and share insights. Based on our findings, we deduce recommendations on how to improve the design of existing DVEs, to create new DVEs, as well as to plan DVE projects and events.
... Harvey and colleagues [33] conducted a concept analysis of facilitation and presented the role of the facilitator as one of "supporting people to change their practice". This HealthWISE study used appointed facilitators, external to the hospitals, who focused on building capacity in OHS in order to enable change, all which fit within the defining characteristics of facilitation that they describe. ...
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Ways to address the increasing global health workforce shortage include improving the occupational health and safety of health workers, particularly those in high-risk, low-resource settings. The World Health Organization and International Labour Organization designed HealthWISE, a quality improvement tool to help health workers identify workplace hazards to find and apply low-cost solutions. However, its implementation had never been systematically evaluated. We, therefore, studied the implementation of HealthWISE in seven hospitals in three countries: Mozambique, South Africa, and Zimbabwe. Through a multiple-case study and thematic analysis of data collected primarily from focus group discussions and questionnaires, we examined the enabling factors and barriers to the implementation of HealthWISE by applying the integrated Promoting Action on Research Implementation in Health Services (i-PARiHS) framework. Enabling factors included the willingness of workers to engage in the implementation, diverse teams that championed the process, and supportive senior leadership. Barriers included lack of clarity about how to use HealthWISE, insufficient funds, stretched human resources, older buildings, and lack of incident reporting infrastructure. Overall, successful implementation of HealthWISE required dedicated local team members who helped facilitate the process by adapting HealthWISE to the workers’ occupational health and safety (OHS) knowledge and skill levels and the cultures and needs of their hospitals, cutting across all constructs of the i-PARiHS framework.
... The core function here is to disrupt deficit narratives and to help members to see differently (Panero, 2020;Park, 2018;Sassi & Nelson, 1999). The third prioritizes evidence-use, and specifically, the facilitator's skill in getting evidence into practice (Harvey et al., 2002;Park, 2018). Although each camp emphasizes one aspect, in practice these aspects (or subroles) overlap to enact their culture-shifting function. ...
Article
Existing literature points to skilled facilitation as a key factor in enabling a team’s success in the context of inquiry-based reform. There is little understanding, however, of how precisely facilitators make the needed difference. This study analyzes the moves of expert facilitators in a team-based reform found to be successful previously. It identifies and explicates five distinct categories of needed moves (setting expectations, modeling, tracking progress, suggesting remediation, and releasing) as well as how they gain effectiveness as an interconnected system with moves across categories implemented for multiple purposes simultaneously.
... The qualitative study highlighted the importance of facilitators receiving training before running the intervention, and supervision and support during the intervention. The role of the facilitator has been identified as an important change agent in the success of intervention implementation (Harvey et al., 2002) and thus requires appropriate support. ...
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Foster carers require high-quality training to support them in caring for children with trauma-related difficulties. This paper describes a mixed methods approach that was applied to evaluate the complex intervention Fostering Connections: The Trauma-Informed Foster Care Programme, a recently developed trauma-informed psychoeducational intervention for foster carers in Ireland. A quantitative outcome evaluation and a qualitative process evaluation were integrated to capture a comprehensive understanding of the effects of this complex intervention. A convergent mixed methods model with data integration was used. Coding matrix methods were employed to integrate data. There was convergence among component studies for: programme acceptability, increased trauma-informed foster caring, improvement in child regulation and peer problems, and the need for ongoing support for foster carers. This research provides support for the intervention suggesting the importance of its implementation in Ireland. The integrative findings are discussed in relation to effects and future implementation.
... Implementation scientists have shown an interest in how to best support frontline staff, that is, those involved in the delivery of services to children, adults, families, and communities, in their uptake of research-supported interventions (RSIs) since the early beginnings of the field (Harvey et al., 2002;Kitson et al., 1998;Schoenwald et al., 2004). RSIs-be they programs, strategies, procedures, or policies-are those that have been "evaluated using acceptable standards of scientific evidence and found to yield generally positive outcomes" (Thyer et al., 2017, p. 86) for their target populations. ...
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Purpose Skills in selecting and designing strategies for implementing research-supported interventions (RSIs) within specific local contexts are important for progressing a wider RSI adoption and application in human and social services. This also applies to a particular role in implementation, the implementation support practitioner (ISP). This study examines which strategies have been reported as being used by ISPs across multiple bodies of research on implementation support and how these strategies were applied in concrete practice settings. Methods A systematic integrative review was conducted. Data analysis utilized the Expert Recommendations for Implementing Change compilation of implementation strategies. Results Studies reported on 18 implementation strategies commonly used by different ISPs, who require mastery in selecting, operationalizing, and detailing these. Two further strategies not included in the ERIC compilation could be identified. Discussion Given the use of primarily more feasible implementation support strategies among ISPs, their potential as agents of change may be underutilized.
... 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. ...
... Facilitators often need to respond "in the moment" rather than in predetermined ways [4][5][6]. Facilitation is thus a relational practice [7][8][9]. Facilitators need to know when and how to intervene to be effective. They also require multiple, complex skills to guide people through change processes [10], using external benchmarks and understandings of local context. ...
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Background Facilitation is a complex, relational implementation strategy that guides change processes. Facilitators engage in multiple activities and tailor efforts to local contexts. How this work is coordinated and shared among multiple, external actors and the contextual factors that prompt and moderate facilitators to tailor activities have not been well-described. Methods We conducted a mixed methods evaluation of a trial to improve the quality of transient ischemic attack care. Six sites in the Veterans Health Administration received external facilitation (EF) before and during a 1-year active implementation period. We examined how EF was employed and activated. Data analysis included prospective logs of facilitator correspondence with sites (160 site-directed episodes), stakeholder interviews (a total of 78 interviews, involving 42 unique individuals), and collaborative call debriefs ( n =22) spanning implementation stages. Logs were descriptively analyzed across facilitators, sites, time periods, and activity types. Interview transcripts were coded for content related to EF and themes were identified. Debriefs were reviewed to identify instances of and utilization of EF during site critical junctures. Results Multi-tiered EF was supported by two groups (site-facing quality improvement [QI] facilitators and the implementation support team) that were connected by feedback loops. Each site received an average of 24 episodes of site-directed EF; most of the EF was delivered by the QI nurse. For each site, site-directed EF frequently involved networking (45%), preparation and planning (44%), process monitoring (44%), and/or education (36%). EF less commonly involved audit and feedback (20%), brainstorming solutions (16%), and/or stakeholder engagement (5%). However, site-directed EF varied widely across sites and time periods in terms of these facilitation types. Site participants recognized the responsiveness of the QI nurse and valued her problem-solving, feedback, and accountability support. External facilitators used monitoring and dialogue to intervene by facilitating redirection during challenging periods of uncertainty about project direction and feasibility for sites. External facilitators, in collaboration with the implementation support team, successfully used strategies tailored to diverse local contexts, including networking, providing data, and brainstorming solutions. Conclusions Multi-tiered facilitation capitalizing on emergent feedback loops allowed for tailored, site-directed facilitation. Critical juncture cases illustrate the complexity of EF and the need to often try multiple strategies in combination to facilitate implementation progress. Trial registration The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) is a registered trial ( NCT02769338 ), May 11, 2016—prospectively registered.
... Nonetheless, the strength of our study includes that exploring the determinants of optimal PIVC decision-making and management as experienced and constructed by nurses would enable the development of tailored quality improvement interventions [39]. Understanding contextual features is a rst required step before effective knowledge transference at different levels [40,41]. To further understand the interaction between PIVCs policies and stakeholders, we plan to carry out a follow-up study with managers and decisionmakers which will provide contextual insights of meso and macro levels and elicit crucial information on barriers and facilitators. ...
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Background: Peripheral intravenous catheters (PIVC) are commonly used in hospital worldwide. However, PIVC are not exempt from complications. Catheter-related bloodstream infections (CRBSI) increase morbidity and mortality rates, and costs for the healthcare organization. PIVC care is shaped by the complex mix of professional and organizational culture, such as knowledge gaps, low perception of impact of PIVCs on patient safety, or lack of hospital guidelines. Aim: To explore determinants of decision-making about the prevention of PIVC-BSI among nurses in Spanish hospitals. Methods: We conducted a descriptive qualitative study with semi-structured interviews in three public hospitals, the Balearic Islands Health Care Service in Spain. We considered hospital ward nurses working routinely with inpatients at any of the three hospitals for enrolment in the study. We approached relevant informants to identify suitable participants who recruited other participants through a ‘snowball’ technique. Fourteen inpatient nurses from the hospital took part in this study between September and November 2018. We employed several triangulation strategies to underpin the methodological rigour of our analysis and conducted the member checking, showing the information and codes applied in the recording of the interviews to identify the coherence and any discrepancies of the discourse by participants. We used the COREQ checklist for this study. Findings: We identified four major themes in the analysis related to determinants of care: The fog of decision-making in PIVC; The taskification of PIVC care; PIVC care is accepted to be suboptimal, yet irrelevant; and PIVC care gaps may reflect behavioural shortcomings, yet solutions proposed to involve education and training. Conclusion: The clinical management of PIVCs appear ambiguous, unclear, and fragmented, with no clear professional responsibility and no nurse leadership, causing a gap in preventing infections. Furthermore, the perception of low risk on PIVC care impact can cause a relevant lack of adherence to the best evidence and patient safety. Implementing facilitation strategies could improve the fidelity of the best available evidence regarding PIVC care and raise awareness among nurses of impact that excellence of care.
... However, given implementation and sustainment are acknowledged as multilevel processes (Aarons et al., 2011;Proctor et al., 2009), the ATTC strategy, which mostly focuses on individual staff training (i.e., staff-focused), was hypothesized to be necessary but not sufficient. Thus, building upon research that identified facilitation as a promising strategy (Baskerville et al., 2012;Cully et al., 2012;Gustafson et al., 2013;Harvey et al., 2002;Kauth et al., 2010;Kitson et al., 2008;Liddy et al., 2011;Owen et al., 2013;Parchman et al., 2013;Seers et al., 2012;Stetler et al., 2006), we aimed to test the ISF strategy, which focuses on training the staff in MIBI and the organization's leadership (i.e., team-focused) to support MIBI implementation. ...
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Background Substance use disorders (SUDs) among people with HIV are both prevalent and problematic. The Substance Abuse Treatment to HIV care project was funded to test the Implementation and Sustainment Facilitation (ISF) strategy as an adjunct to the Addiction Technology Transfer Center (ATTC) strategy for integrating a motivational interviewing-based brief intervention (MIBI) for SUDs within HIV community-based organizations. Methods Using a cluster-randomized, type 2 hybrid trial design, 39 HIV organizations were randomized to either (1) ATTC ( n = 19) or (2) ATTC + ISF ( n = 20). Each HIV organization identified two staff members to be prepared to implement the MIBI ( N = 78). Subsequently, during the implementation phase, HIV organizations in each condition randomized client participants ( N = 824) to one of the two intervention conditions: usual care (UC; n = 415) or UC + MIBI ( n = 409). Both staff-level outcomes and client-level outcomes were examined. Results The ISF strategy had a significant impact on the implementation effectiveness (i.e., the consistency and the quality of implementation; β = .65, p = .01) but not on time-to-proficiency (β = −.02) or level-of-sustainment (β = .09). In addition, the ISF strategy was found to have a significant impact on the intervention effectiveness (the effectiveness of the MIBI), at least in terms of significantly decreasing the odds (odds ratio = 0.11, p = .02) of clients using their primary substance daily during follow-up. Conclusion The ISF strategy was found to be an effective adjunct to the ATTC strategy in terms of implementation effectiveness and intervention effectiveness. It is recommended that future efforts to integrate the project’s MIBI for SUD within HIV organizations use the ATTC + ISF strategy. However, given the ISF strategy did not have a significant impact on level-of-sustainment, implementation research testing the extent to which the ATTC + ISF strategy can be significantly enhanced through effective sustainment strategies is warranted. Plain language abstract Substance use among people living with HIV is associated with increased mental health problems, worse medication adherence, and worse HIV viral suppression. Increasing substance use-related services in HIV community-based organizations is an important public health need. The Substance Abuse Treatment to HIV care project tested two strategies for helping HIV organizations implement a brief intervention (BI) designed to motivate clients to decrease their substance use. The project also tested if receiving a BI improved clients’ outcome. Two staff from each of the 39 participating organizations were taught how to deliver the BI using the Addiction Technology Transfer Center (ATTC) training strategy (online and in-person training, monthly feedback, and coaching). Half of the organizations also received the Implementation and Sustainment Facilitation (ISF) strategy, which included monthly meetings with an ISF coach for the two BI staff and one or more leadership staff from the organization. Organizations that received both the ATTC and ISF strategies delivered more BIs and higher quality BIs than organizations that only received the ATTC strategy. In addition, clients receiving BIs at organizations that received both strategies were more likely to decrease their substance use. However, receiving both strategies did not improve how quickly staff learned to deliver the BI or improve the number of BIs delivered during the project’s 6-month sustainment phase. Future research focused on implementing BIs within HIV organizations should consider using the ATTC and ISF strategies while also seeking to enhance the strategies to improve sustainment.
... A variety of implementation strategies have been used to help clinic teams build their capacity for therapy delivery, integrate the new practice into their clinical context, and foster sustainability (Nadeem et al., 2013). Two commonly used approaches are external facilitation (Harvey et al., 2002;Powell et al., 2015;Stetler et al., 2006) and learning collaboratives (e.g., Hanson et al., 2019;LoSavio et al., 2019). In external facilitation, an outside coach supports and advises a local site champion, who works with their clinic team to develop and enact implementation plans that are tailored to their particular circumstance (Ritchie et al., 2017;Stetler et al., 2006). ...
Article
In response to COVID‐19, continued workforce training is essential to ensure that evidence‐based treatments are available on the frontline to meet communities’ ongoing and emerging mental health needs. However, training during a pandemic imposes many new challenges. This paper describes a multisite training and implementation pilot program, facets of which allowed for continued training despite the onset of the COVID‐19 pandemic and subsequent social distancing guidelines. This virtual facilitated learning collaborative in Written Exposure Therapy, an evidence‐based treatment for posttraumatic stress disorder, included virtual workshop training, phone‐based clinical consultation, implementation‐focused video calls for program leadership, and program evaluation. Data are presented about program enrollees and patient impact following the onset of COVID‐19–related social distancing restrictions. Challenges, successes, and practical guidance are discussed to inform the field regarding training strategies likely to be durable in an uncertain, dynamic healthcare landscape.
... The method used to screen the "prevalent" or "most needed" "best" evidence is the first decision to be considered by each researcher or EI facilitator; that is, the starting point for EI is based on clinical problems that need to be solved or improved rather than the individual interests of the researcher. It is necessary to correctly understand "to what degree evidence and policies of the EI site, practices and priorities match" [30]. Whether the evidence can meet the main objectives of organizational development at the current stage will certainly affect the smooth implementation of the evidence in clinical practice [31]. ...
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Objectives To explore how to integrate the “best” practice into nursing of venous thromboembolism (VTE) based on the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Methods A mixed-methods design was used. A steering group for clinical evidence implementation (EI) was established to conduct pre-implementation baseline surveys, a thorough analysis of the evidence, and an analysis of the survey results. The hindering and enabling factors associated with the clinical implementation of the evidence were analysed based on the three core elements of i-PARIHS, to formulate the clinical implementation plan for VTE nursing evidence. On-site expert reviews and focus group interviews were used to evaluate the feasibility of the draft plan, make adjustments, and finalize the evidence-based practice plan, which was then put into practice and evaluated. Results A new nursing process, a health education manual and a nursing quality checklist on VTE has been established and proved to be appropriate through the implementation. Compliance with evidence related to VTE nursing increased significantly in the two units, with better compliance in unit B than unit A. The knowledge, attitude and behaviour scores for VTE nursing increased substantially in both nurses and patients. Conclusion The EI programme of incorporating the “best” evidence on VTE nursing into clinical practice using the i-PARIHS framework demonstrated feasibility, appropriateness and effectiveness and could serve as a reference.
... While i-PARIHS is ideal to inform implementation strategy tailoring, research has not tested it in this way. Further, i-PARIHS has received limited tests of underlying mechanisms [43][44][45], with most studies in health care [46,47]. ...
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Background: Despite the potential for Early Care and Education (ECE) settings to promote healthy habits, a gap exists between current practices and evidence-based practices (EBPs) for obesity prevention in childhood. Methods: We will use an enhanced non-responder trial design to determine the effectiveness and incremental cost-effectiveness of an adaptive implementation strategy for Together, We Inspire Smart Eating (WISE), while examining moderators and mediators of the strategy effect. WISE is a curriculum that aims to increase children's intake of carotenoid-rich fruits and vegetables through four evidence-based practices in the early care and education setting. In this trial, we will randomize sites that do not respond to low-intensity strategies to either (a) continue receiving low-intensity strategies or (b) receive high-intensity strategies. This design will determine the effect of an adaptive implementation strategy that adds high-intensity versus one that continues with low-intensity among non-responder sites. We will also apply explanatory, sequential mixed methods to provide a nuanced understanding of implementation mechanisms, contextual factors, and characteristics of sites that respond to differing intensities of implementation strategies. Finally, we will conduct a cost effectiveness analysis to estimate the incremental effect of augmenting implementation with high-intensity strategies compared to continuing low-intensity strategies on costs, fidelity, and child health outcomes. Discussion: We expect our study to contribute to an evidence base for structuring implementation support in real-world ECE contexts, ultimately providing a guide for applying the adaptive implementation strategy in ECE for WISE scale-up. Our work will also provide data to guide implementation decisions of other interventions in ECE. Finally, we will provide the first estimate of relative value for different implementation strategies in this setting. Trial registration: NCT05050539 ; 9/20/21.
... There is evidence from practice development initiatives in particular that expert facilitation is key to success (Hardiman & Dewing, 2019;Mekki et al., 2017;Raelin, 2012;Webster & Dewing, 2007). Indeed, Harvey et al. (2002) in their concept analysis of facilitation describe the purpose of facilitation as being to support, and to enable people to analyse current practice, which in turn leads to change in behaviour and work practices. This is borne out in our study where staff relied on the facilitators to enable them look critically at their current practice and to assist with identifying ways to implement the guidance document. ...
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Background: Dementia affects a large proportion of society and places a significant burden on older people and healthcare systems internationally. Managing symptoms at the end of life for people with dementia is complex. Participatory action research can offer an approach that helps to encourage implementation of evidence-based practices in long-term care settings. Methods: Three evidence-based guidance documents (pain assessment and management, medication management, nutrition and hydration management) were introduced in three long-term care settings for older people. Data generated from work-based learning groups were analysed using a critical hermeneutic approach to explore the use of participatory action research to support the implementation of guidance documents in these settings. Results: Engagement and Facilitation emerged as key factors which both enabled and hindered the PAR processes at each study site. Conclusions: This study adds to the body of knowledge that emphasises the value of participatory action research in enabling practice change. It further identifies key practice development approaches that are necessary to enable a PAR approach to occur in care settings for older people with dementia. The study highlights the need to ensure that dedicated attention is paid to strategies that facilitate key transformations in clinical practice.
... In an effort to support teams, improvement coaches may serve as a resource (Swanson & Pearlman, 2017), help build capacity for change, (Nguyen et al., 2020), facilitate the customisation of interventions (Nguyen et al., 2020) or encourage best practices in communication, problem solving and vision development . Notably, the role of an improvement coach exists on a continuum from task-driven (in relation to specific project steps) to holistic (to support the QI capacity of a team) (Harvey et al., 2002). ...
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Background: Healthcare organisations and teams perform improvement activities to facilitate high-quality healthcare. The use of an improvement coach who provides support and guidance to the healthcare team may facilitate improvement activities; however, no systematic review exists on the facilitators and barriers to implementing an improvement coach. Aims: We conducted a qualitative evidence synthesis to examine the facilitators and barriers to the implementation of improvement coaching. Methods: We searched MEDLINE® , Embase and CINAHL. The final search was in March 2021. The screening eligibility criteria included the following: interdisciplinary team receiving the coaching, improvement coaching, designs with a qualitative component and primary purpose of evaluating practice facilitation in OECD countries. An ecologically-informed consolidated framework for implementation research (CFIR) served as the framework for coding. Patterns of barriers and facilitators across domains were identified through matrix analysis. Risk of bias was assessed using Critical Appraisal Skills Program. PRISMA reporting guidelines served as a guide for reporting this review. Results: Nineteen studies with a qualitative component met the inclusion criteria. Four themes of barriers and facilitators crossed multiple CFIR domains: adaptability (e.g. making adjustments to the project; process, or approach); knowledge and skills (e.g. understanding of content and process for the project); engagement (e.g. willingness to be involved in the process) and resources (e.g. assets required to complete the improvement process). Conclusion: Improvement coaching is a complex intervention that influences the context, healthcare team being coached and improvement activities. Improvement coaches should understand how to minimise barriers and promote facilitators that are unique to each improvement project across the domains. Limitations of the study are related to the nature of the intervention including potential publication bias given quality improvement focus; the variety of terms similar to improvement coaching or selection of framework.
... The individuals implementing the new process should perform a preimplementation plan to better understand the organization/ clinic's culture and understanding of the use of the new guideline in order to develop the best facilitation strategies to be utilized. [29][30][31] Even after the usual implementation of the STEADI in the EMR, the majority of the clinic staff continued to use the old, two-question fall-risk screening format. This may be in part because there were no de-implementation strategies used. ...
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Background: Although falls are the leading cause of morbidity and mortality in the US in the older adult population, there is little information regarding implementation of evidence-based fall prevention guidelines within primary care settings. The objective of this study was to address this gap in the literature by determining the effectiveness of the use of education and written materials as implementation strategies. Methods: Using a prospective, mixed methods, controlled before-and-after study design, we studied the effect of the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) education and written materials on knowledge and intention to use in primary care clinics as well as test the screening, assessment, and intervention behaviors. This manuscript details the quantitative findings of the study, using STEADI Knowledge Test, Continuing Professional Development (CPD) Reaction Questionnaire, and EMR Reports. We compared data between the study arms (usual implementation versus education implementation) using descriptive statistics, paired t-tests, and factorial ANOVAs. Results: In total, data from 29 primary care staff, including physicians, APRNs, RNs, and medical assistants, were analyzed. Although we found a statistically significant difference within the education arm between immediate pretests and posttests/surveys mean scores, there was no statistically significant difference between the study arms' knowledge, intent to use STEADI, or use behaviors. The pre/immediate post education mean knowledge score increased by 1.19 (p= 0.02) and the pre/immediate post education intent to use mean increased by 0.64 (p 0.01). There was no statistically significant change between the study arms over time. Conclusion: Educational strategies, particularly written materials and an online module, did not increase the long-term use of the STEADI toolkit. Implementation research is needed to identify the strategies that are most effective for promoting the adoption of STEADI in primary care.
... From the point of view of safety and quality of care, healthcare organizations should emphasize clinical implementation strategies [39] and delve deeper into their understanding of internal decision-making processes [40]. This strategy should incorporate mechanisms to mediate knowledge into decision-making [41,42], which is not only achieved through the careful selection of evidence but also the weight of multiple humans factors [22]. ...
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Background Peripheral intravenous catheters (PIVCs) are the most widely used invasive devices worldwide. Up to 42% of PIVCs are prematurely removed during intravenous therapy due to failure. To date, there have been few systematic attempts in European hospitals to measure adherence to recommendations to mitigate PIVC failures. Aim To analyse the clinical outcomes from clinical practice guideline recommendations for PIVC care on different hospital types and environments. Methods We conducted an observational study in three hospitals in Spain from December 2017 to April 2018. The adherence to recommendations was monitored via visual inspection in situ evaluations of all PIVCs inserted in adults admitted. Context and clinical characteristics were collected by an evaluation tool, analysing data descriptively. Results 646 PIVCs inserted in 624 patients were monitored, which only 52.7% knew about their PIVC. Regarding PIVC insertion, 3.4% (22/646) patients had at least 2 PIVCs simultaneously. The majority of PIVCs were 20G (319/646; 49.4%) and were secured with transparent polyurethane dressing (605/646; 93.7%). Most PIVCs (357/646; 55.3%) had a free insertion site during the visual inspection at first sight. We identified 342/646 (53%) transparent dressings in optimal conditions (clean, dry, and intact dressing). PIVC dressings in medical wards were much more likely to be in intact conditions than those in surgical wards (234/399, 58.7% vs. 108/247, 43.7%). We identified 55/646 (8.5%) PIVCs without infusion in the last 24 hours and 58/646 (9.0%) PIVCs without infusion for more than 24 hours. Regarding PIVC failure, 74 (11.5%) adverse events were identified, all of them reflecting clinical manifestation of phlebitis. Conclusions Our findings indicate that the clinical outcome indicators from CPG for PIVC care were moderate, highlighting differences between hospital environments and types. Also, we observed that nearly 50% of patients did not know what a PIVC is.
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This process study explored the experiences of foster carers and facilitators who participated in Fostering Connections: The Trauma-informed Foster Care Program which was implemented in 2017 in the national child welfare agency in Ireland. This intervention was a psychoeducational program for foster carers, developed in respond to a gap in training provision. Three focus groups were carried out with foster carers and facilitators that participated in the intervention. Thematic analysis revealed four overarching themes: 1. Facilitating the reflective process 2. Transformative learning, 3. The carer-child relationship and 4. Sustainability. Findings suggest that Fostering Connections is highly acceptable to Irish foster carers. They experienced a process of change during the programme that led to them providing children with trauma-informed care. This was associated with more positive child-carer interactions and reduced observed child difficulties. However, to successfully sustain the changes foster carers have made, this study suggests ongoing supports for foster carers, training for the wider stakeholders in foster care and supports for facilitators are needed.
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In healthcare, evidence-based practice (EBP) integrates clinical expertise with the best available external evidence from systematic research. Yet even with the aid of technology, implementation of EBP in many settings remains a challenge due in part to the complexity of the healthcare system and the lack of a strong theoretical and analytical foundation to guide implementation efforts. This paper combines research from the fields of healthcare implementation science and social networks to present a theoretically based, integrated framework for the study of EBP implementation. This study explores the application of the framework to a complex healthcare collaborative, the MRSA infection control project, a project intended to foster the implementation of EBP to reduce the spread of MRSA infections. The authors consider how the framework can also be used to inform future research into EBP-related information system implementations and innovations.
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The rate of change in the use of digital technologies in schools means that professional learning regarding technology-enhanced learning is constantly required for school teachers. The focus of this article is on how an action learning (AL) approach supported the professional learning of teachers regarding adoption of mobile technologies in their teaching. In particular, the article investigates the role of facilitation in the action learning process and explores an AL process implemented at two schools, one a primary school and the other a secondary school. Drawing on qualitative methodology, a multi-site case study using observations, field notes and interviews was implemented to investigate the effectiveness of the AL approach. It was found that different kinds of facilitation were central to the success of the process, and that facilitation impacted on teacher agency. The article concludes with recommendations for action learning projects.
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Background: The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework. Methods: This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail. Results: The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated. Conclusions: In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.
Article
Purpose To explore the role of leadership by physiotherapists in implementing and sustaining an evidence-based complex intervention (ESCAPE-pain) for osteoarthritis. Materials and methods A qualitative case study approach using in-depth interviews with 23 clinicians and managers from 4 National Health Service (NHS) physiotherapy providers in England between 2016 and 2017. Data were analysed using thematic analysis. Results Different leadership roles and actions were characterised with four themes: (1) Clinical champions – clinicians driving the sustainability of ESCAPE-pain; (2) Supporters – junior clinicians directly supporting clinical champions’ efforts to sustain ESCAPE-pain; (3) Senior Manager – clinical champions’ senior managers influence on sustainability; (4) Decision-making – (in)formal processes underpinning decisions to (not) sustain the programme. Conclusions The study characterises the role of leadership in physiotherapy to sustain an evidence-based intervention for osteoarthritis (OA) within the NHS. Sustaining the intervention required on-going leadership, it did not stop at implementation. Senior specialist physiotherapists (as Champions) had a critical leadership role in driving sustainability. Their structural position (bridging the operational and strategic) and personal attributes allowed them to integrate different levels of leadership (i.e., senior managers and operational staff) to mobilise the collective, on-going work required for sustaining the programme. • IMPLICATIONS FOR REHABILITATION • Senior managers and clinicians in practice settings need to be aware that sustaining an intervention is an on-going, collective effort that continues post-implementation. • Senior managers need to enable senior clinicians (who straddle strategic and operational functions) to have sufficient autonomy to access and mobilise resources and scope to restructure local systems and practice to support intervention sustainability. • Operational staff need to be supported to have the practical know-how to deliver evidence-based intervention, which includes instilling the value of and a commitment for the interventions. • Managers need to utilise dispersed leadership to empower and enthuse frontline clinicians to participate fully in the work to refine and sustain interventions, because it cannot be achieved by lone individuals.
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Background: Practice facilitation is a promising strategy to enhance care processes and outcomes in primary care settings. It requires that practices and their facilitators engage as teams to drive improvement. In this analysis, we explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month practice facilitation intervention focused on implementing cardiovascular prevention activities in practice. Understanding factors associated with greater engagement with facilitators in practice-based quality improvement can assist practice facilitation programs with planning and resource allocation. Methods: One hundred thirty-six ambulatory care small to medium sized primary care practices that participated in the EvidenceNow initiative's NC Cooperative, named Heart Health Now (HHN), fit the eligibility criteria for this analysis. We explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month intervention using a retrospective cohort design that included baseline survey data, monthly practice activity implementation data and information about facilitator's experience. Generalized linear mixed-effects models (GLMMs) identified variables associated with greater odds of team engagement using an ordinal scale for level of team engagement. Results: Among our practice cohort, over half were clinician-owned and 27% were Federally Qualified Health Centers. The mean number of clinicians was 4.9 (SD 4.2) and approximately 40% of practices were in Medically Underserved Areas (MUA). GLMMs identified a best fit model. The Model presented as odd ratios and 95% confidence intervals suggests greater odds ratios of higher team engagement with greater practice QI leadership 17.31 (5.24-57.19), [0.00], and practice location in a MUA 7.25 (1.8-29.20), [0.005]. No facilitator characteristics were independently associated with greater engagement. Conclusions: Our analysis provides information for practice facilitation stakeholders to consider when considering which practices may be more amendable to embracing facilitation services.
Chapter
Translation of evidence into practice requires conscious effort. Theories are presented and critically discussed as potential clues of how to best pull evidence into practice and reap rewards for the effort. Translation is considered in the context of the individual practitioner, institution and nursing profession. The role of informatics is situated in these contexts.
Article
The aims of this systematic review were to describe, critique, and summarize research about the effects of education about urinary incontinence on nurses' and nursing assistants' knowledge and attitudes toward urinary incontinence, their continence care practices, and patient outcomes. We searched key electronic databases (PsycINFO, MEDLINE, CINAHL, Web of Science, and Cochrane Library) for full-text primary research articles written in the English language and published between January 1990 and October 2018. Studies were included if they described a controlled or uncontrolled trial of an education program for nurses or nursing assistants about urinary incontinence and evaluated the effects of the program on either knowledge, attitudes, practice, or patient outcomes. Data were extracted about the aim, design, sample and setting, trial methods, intervention, outcomes of interest, and findings. Quality appraisal was conducted using a mixed-methods appraisal tool. Results are presented in tabular format and reported descriptively. Nineteen studies met inclusion criteria; most were set in the United States or the UK. All trials that evaluated the effects on knowledge reported improvements; however, the effects of education on attitudes were mixed as were the effects of education on continence care practices. Eleven of the 19 studies reported the statistical effect of education on patient outcomes. Uncontrolled trials reported improvements in nursing home residents' and community-dwelling patients' continence status, but this effect was not observed in a large controlled trial. Similarly, 2 studies set in inpatient rehabilitation found no significant differences in patient continence outcomes following an educational intervention targeted to nurses.
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Patients receiving healthcare are commonly exposed to harm that is systematic and often severe. Clinical decisions based on inaccurate sources of information can lead to medical errors, high treatment costs, and poor patient outcomes. Evidence-based practice has the potential to overcome these problems by improving clinical decision-making processes. The PARIHS framework was developed to address the inability of traditional unidimensional models to successfully implement evidence-based practice. The PARIHS framework proposes that successful implementation of evidence into practice is a function of evidence, culture, and facilitation. The PARIHS framework can be used to design, implement, and evaluate knowledge translation projects at both acute and chronic care facilities. This chapter discusses the PARIHS framework as well as its advantages for implementing change at a healthcare setting compared to traditional models. The chapter also outlines a feasible knowledge translation project based on the principles of the PARIHS framework while highlighting health informatics and availability of easily accessible high quality patient outcome data as key enablers in designing and successfully implementing such a project at a healthcare setting.
Article
Objective To evaluate the comparative effectiveness of external facilitation (EF) vs external + internal facilitation (EF/IF), on uptake of a collaborative chronic care model (CCM) in community practices that were slower to implement under low‐level implementation support. Study Setting Primary data were collected from 43 community practices in Michigan and Colorado at baseline and for 12 months following randomization. Study Design Sites that failed to meet a pre‐established implementation benchmark after six months of low‐level implementation support were randomized to add either EF or EF/IF support for up to 12 months. Key outcomes were change in number of patients receiving the CCM and number of patients receiving a clinically significant dose of the CCM. Moderators’ analyses further examined whether comparative effectiveness was dependent on prerandomization adoption, number of providers trained or practice size. Facilitation log data were used for exploratory follow‐up analyses. Data Collection Sites reported monthly on number of patients that had received the CCM. Facilitation logs were completed by study EF and site IFs and shared with the study team. Principal Findings N = 21 sites were randomized to EF and 22 to EF/IF. Overall, EF/IF practices saw more uptake than EF sites after 12 months (ΔEF/IF‐EF = 4.4 patients, 95% CI = 1.87‐6.87). Moderators' analyses, however, revealed that it was only sites with no prerandomization uptake of the CCM (nonadopter sites) that saw significantly more benefit from EF/IF (ΔEF/IF‐EF = 9.2 patients, 95% CI: 5.72, 12.63). For sites with prerandomization uptake (adopter sites), EF/IF offered no additional benefit (ΔEF/IF‐EF = −0.9; 95% CI: −4.40, 2.60). Number of providers trained and practice size were not significant moderators. Conclusions Although stepping up to the more intensive EF/IF did outperform EF overall, its benefit was limited to sites that failed to deliver any CCM under the low‐level strategy. Once one or more providers were delivering the CCM, additional on‐site personnel did not appear to add value to the implementation effort.
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Background There are increasing expectations for researchers and knowledge users in the health system to use a research partnership approach, such as integrated knowledge translation, to increase the relevance and use of research findings in health practice, programmes and policies. However, little is known about how health research trainees engage in research partnership approaches such as IKT. In response, the purpose of this scoping review was to map and characterize the evidence related to using an IKT or other research partnership approach from the perspective of health research trainees in thesis and/or postdoctoral work. Methods We conducted this scoping review following the Joanna Briggs Institute methodology and Arksey and O’Malley’s framework. We searched the following databases in June 2020: MEDLINE, Embase, CINAHL and PsycINFO. We also searched sources of unpublished studies and grey literature. We reported our findings in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Results We included 74 records that described trainees’ experiences using an IKT or other research partnership approach to health research. The majority of studies involved collaboration with knowledge users in the research question development, recruitment and data collection stages of the research process. Intersecting barriers to IKT or other research partnerships at the individual, interpersonal and organizational levels were reported, including lack of skills in partnership research, competing priorities and trainees’ “outsider” status. We also identified studies that evaluated their IKT approach and reported impacts on partnership formation, such as valuing different perspectives, and enhanced relevance of research. Conclusion Our review provides insights for trainees interested in IKT or other research partnership approaches and offers guidance on how to apply an IKT approach to their research. The review findings can serve as a basis for future reviews and primary research focused on IKT principles, strategies and evaluation. The findings can also inform IKT training efforts such as guideline development and academic programme development.
Article
Background Most hospitals use physiological signs to trigger an urgent clinical review. We investigated whether facilitation could improve nurses’ vital sign measurement, interpretation, treatment and escalation of care for deteriorating patients. Methods In a pragmatic cluster randomised controlled trial, we randomised 36 inpatient wards at four acute hospitals to receive standard clinical practice guideline (CPG) dissemination to ward staff (n=18) or facilitated implementation for 6 months following standard dissemination (n=18). Expert, hospital and ward facilitators tailored facilitation techniques to promote nurses’ CPG adherence. Patient records were audited pre-intervention, 6 and 12 months post-intervention on randomly selected days. Escalation of care as per hospital policy was the primary outcome at 6 and 12 months after implementation. Patients, nurses and assessors were blinded to group assignment. Analysis was by intention-to-treat. Results From 10 383 audits, improved escalation as per hospital policy was evident in the intervention group at 6 months (OR 1.47, 95% CI (1.06 to 2.04)) with a complete set of vital sign measurements sustained at 12 months (OR 1.22, 95% CI (1.02 to 1.47)). There were no significant differences in escalation of care as per hospital policy between study groups at 6 or 12 months post-intervention. After adjusting for patient and hospital characteristics, a significant change from T0 in mean length of stay between groups at 12 months favoured the intervention group (−2.18 days, 95% CI (−3.53 to –0.82)). Conclusion Multi-level facilitation significantly improved escalation as per hospital policy at 6 months in the intervention group that was not sustained at 12 months. The intervention group had increased vital sign measurement by nurses, as well as shorter lengths of stay for patients at 12 months. Further research is required to understand the dose of facilitation required to impact clinical practice behaviours and patient outcomes. Trial registration number ACTRN12616000544471p
Article
Background: Implementation scientists are identifying evidence-based implementation strategies that support the uptake of evidence-based practices and other clinical innovations. However, there is limited information regarding the development of training methods to educate implementation practitioners on the use of implementation strategies and help them sustain these competencies. Methods: To address this need, we developed, implemented, and evaluated a training program for one strategy, implementation facilitation (IF), that was designed to maximize applicability in diverse clinical settings. Trainees included implementation practitioners, clinical managers, and researchers. From May 2017 to July 2019, we sent trainees an electronic survey via email and asked them to complete the survey at three-time points: approximately 2 weeks before and 2 weeks and 6 months after each training. Participants ranked their knowledge of and confidence in applying IF skills using a 4-point Likert scale. We compared scores at baseline to post-training and at 6 months, as well as post-training to 6 months post-training (nonparametric Wilcoxon signed-rank tests). Results: Of the 102 participants (76 in-person, 26 virtual), there was an increase in perceived knowledge and confidence in applying IF skills across all learning objectives from pre- to post-training (95% response rate) and pre- to 6-month (35% response rate) follow-up. There was no significant difference in results between virtual and in-person trainees. When comparing post-training to 6 months (30% response rate), perceptions of knowledge increase remained unchanged, although participants reported reduced perceived confidence in applying IF skills for half of the learning objectives at 6 months. Conclusions: Findings indicated that we have developed a promising IF training program. Lack of differences in results between virtual and in-person participants indicated the training can be provided to a remote site without loss of knowledge/skills transfer but ongoing support may be needed to help sustain perceived confidence in applying these skills. Plain Language Summary While implementation scientists are documenting an increasing number of implementation strategies that support the uptake of evidence-based practices and other clinical innovations, little is known about how to transfer this knowledge to those who conduct implementation efforts in the frontline clinical practice settings. We developed, implemented, and conducted a preliminary evaluation of a training program for one strategy, implementation facilitation (IF). The training program targets facilitation practitioners, clinical managers, and researchers. This paper describes the development of the training program, the program components, and the results from an evaluation of IF knowledge and skills reported by a subset of people who participated in the training. Findings from the evaluation indicate that this training program significantly increased trainees' perceived knowledge of and confidence in applying IF skills. Further research is needed to examine whether ongoing mentoring helps trainees retain confidence in applying some IF skills over the longer term.
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Background Pain is a central and distressing experience for children in the emergency department (ED). Despite the harmful effects of pain, ED care often falls short of providing timely and effective pain relief. Knowledge translation research targeting systems of care holds potential to transform paediatric pain care. This article reports on the first stages of an implementation project aimed at embedding effective and sustainable practice change in an Australian children’s hospital ED. Methods The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework underpinned a cooperative process of engagement to establish a practitioner-led, interprofessional research collaborative. The Kids Pain Collaborative (KPC) aimed to co-design innovation in paediatric ED pain care, facilitating an extensive reconnaissance of research evidence, clinician and family experiences, and local evaluation data. This critical appraisal of the context and culture of pain management generated foci for innovation and facilitation of implementation action cycles. Results Engaging in a complex process of facilitated critical reflection, the KPC unpacked deeply embedded assumptions and organisational practices for pain care that worked against what they wanted to achieve as a team. A culture of rules-based pain management and command and control leadership produced self-defeating practices and ultimately breakdowns in pain care. By raising a critical awareness of context, and building consensus on the evidence for change, the KPC has established a whole of ED shared vision for prioritising pain care. Conclusions In-depth key stakeholder collaboration and appraisal of context is the first step in innovation of practice change. The KPC provided a space for collaborative enquiry where ED clinicians and researchers could develop context-specific innovation and implementation strategy. We provide an example of the prospective application of i-PARIHS in transforming ED pain care, using a collaborative and participatory approach that has successfully enabled high levels of departmental engagement, motivation and ownership of KPC implementation as the facilitation journey unfolds.
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Background Evidence based interventions (EBIs) can improve patient care and outcomes. Understanding the process for successfully introducing and implementing EBIs can inform effective roll-out and scale up. The Promoting Action on Research Implementation in Health Services (PARIHS) framework can be used to evaluate and guide the introduction and implementation of EBIs. In this study, we used kangaroo mother care (KMC) as an example of an evidence-based neonatal intervention recently introduced in selected Chinese hospitals, to identify the factors that influenced its successful implementation. We also explored the utility of the PARIHS framework in China and investigated how important each of its constructs (evidence, context and facilitation) and sub-elements were perceived to be to successful implementation of EBIs in a Chinese setting. Method We conducted clinical observations and semi-structured interviews with 10 physicians and 18 nurses in five tertiary hospitals implementing KMC. Interview questions were organized around issues including knowledge and beliefs, resources, culture, implementation readiness and climate. We used directed content analysis to analyze the interview transcript, amending the PARIHS framework to incorporate emerging sub-themes. We also rated the constructs and sub-elements on a continuum from “low (weak)”, “moderate” or “high (strong)” highlighting the ones considered most influential for hospital level implementation by study participants. Results Using KMC as an example, our finding suggest that clinical experience, culture, leadership, evaluation, and facilitation are highly influential elements for EBI implementation in China. External evidence had a moderate impact, especially in the initial awareness raising stages of implementation and resources were also considered to be of moderate importance, although this may change as implementation progresses. Patient experience was not seen as a driver for implementation at hospital level. Conclusion Based on our findings examining KMC implementation as a case example, the PARIHS framework can be a useful tool for planning and evaluating EBI implementation in China. However, it’s sub-elements should be assessed and adapted to the implementation setting.
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Purpose Process facilitation as part of a complex intervention for changing or improving practices within workplaces is becoming a common work method. The aim of this study was to investigate what characterizes the process-facilitating role in a complex intervention. Design/methodology/approach The present study focuses on a complex work environment intervention targeting eight organizational units (workplaces) in the Swedish healthcare sector. The study applies a mixed-method approach and has been carried out in two steps. First, a qualitative process evaluation was performed. Secondly, an evaluation was conducted to see to what extent these identified conditions and mechanisms affected the quantitative intervention effect in term of sickness absence. Findings The analysis shows that the facilitating role consisted of three overlapping and partially iterative phases. These phases involved different activities for the facilitating role. Depending on how the facilitating role and the intervention were designed, various supporting conditions were found to significantly affect the outcome of the intervention measured as the total sickness absence. Research limitations/implications It is concluded that the facilitation is not static or fixed during the change process. Instead, the facilitation role develops and emerges through the process of support during the different implementation phases. Practical implications The facilitative role of performing support is based on a combination of support role activities and expert role activities. The support role focuses on support activities, while the expert role includes capacity building through knowledge- and legitimacy-oriented activities. Originality/value This study contributes to earlier research by developing a methodological approach for carrying out process facilitation in complex interventions.
Article
Background Facilitation is an implementation strategy that can help primary care practices improve healthcare quality and build quality improvement (QI) capacity when delivered in a flexible manner by trained professionals. Practice ownership is associated with use of QI. However, little is known about how practices of different ownership participate in external facilitation, and this could inform future initiatives.Objective Using data from EvidenceNOW, we examined how practice ownership influences participation in external facilitation.Study DesignWe used an iterative mixed-methods design.Participants, Approach, and MeasuresWe collected data from practices on practice characteristics (e.g., location, size, payer mix) and ownership type via surveys and from facilitators on the number of hours, encounters, and months each practice had with a facilitator via facilitation logs. Using multivariable linear regression, we examined the association between facilitation and ownership (n = 1117 practices). We conducted semi-structured interviews with EvidenceNOW leadership (n = 12) and facilitators (n = 51) and observed facilitators in a subset of practices (n = 64); we analyzed this qualitative data for patterns of facilitation.Key ResultsIn the fully adjusted model, differences by ownership were non-significant; FQHCs, however, had significantly less participation in facilitation than clinician-owned practices across two measures (unadjusted difference: − 2.83, p < 0.01 for number of encounters, and − 2.04, p < 0.01 for number of months with encounters). Qualitative data showed that Health System and FQHC ownership influenced types of practices enrolled in EvidenceNOW, and suggested that in these practices lower autonomy and greater complexity compared to clinician-owned ownership influenced facilitation participation patterns.Conclusions Practice ownership shaped how but not how much practices participated in external facilitation. This finding highlights the importance of tailoring facilitation approaches based on ownership-related characteristics in future QI initiatives.
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Objective To identify the elements informing the successful implementation of nonpharmacologic physical restraint minimization interventions in adult intensive care unit patients. To map those elements to innovation, context, recipients and facilitation domains of the integrated–Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and to describe the outcomes of those interventions. Methodology A scoping review of studies published in English reporting on restraint minimization interventions in adult intensive care units. We searched seven databases (MEDLINE, CIHAHL, Embase, Web of Science, Cochrane Library, PROSPERO and Joanna Briggs) from inception to 2021. Two authors independently screened articles for inclusion, extracted study characteristics and mapped intervention data to the i-PARIHS domains. Results Seven studies met inclusion criteria. Innovations comprised multicomponent interventions including education, decision aids/protocols and restraint alternatives. No studies utilised an implementation science framework to diagnose the baseline practice context. A commonly reported barrier to restraint minimization was a risk averse culture. Change was mostly driven by the external context (i.e. national regulations). Overall, nurses were the primary facilitators and recipients of practice change. Outcomes were changes in restraint incidence and prevalence abstracted from the medical record. However, no study validated the accuracy of restraint documentation. All studies documented an initial decrease in physical restraint use, but no long-term results were reported. Conclusion Restraint minimization intervention studies report nurse-facilitated multicomponent interventions and short-term practice change. Future restraint minimization research incorporating implementation science frameworks, interprofessional teams and patient/family perspectives is warranted.
Article
Purpose This study aims to identify the critical factors affecting the perception of adolescent students toward interactive online mental health information available on health-related websites. Design/methodology/approach The primary data was collected with the help of an online self–structured questionnaire. The questionnaire includes the identified variables extracted from previous literature related to the mental health information websites using the Likert scale. The respondents include the adolescent school students belonging to the northern region of India: semi-urban/rural locations of Uttar Pradesh (Agra and Mathura) and urban cities (Faridabad, Gaziabad, Delhi and NCR). The criteria for selecting respondents were that students must have visited any online health information-related websites at least once. Exploratory factor analysis was used to explore the factors with the help of SPSS.20. Findings The identified factors that include information delivery medium/mode, websites’ navigation structure, customized information or content, ability to form a virtual relationship and supplementary features of the websites may benefit the health communication system of any country and the health-care industry. Research limitations/implications There are some limitations such as a limited number of respondents and even on that sample was taken for teenagers; thereby creating fewer generalizations related to the present context. Further, only exploratory factor analysis is applied in the study to identify the factors but future researchers may proceed to develop the conceptual model of perception toward online information with the help of confirmatory factor analysis and structural equation modeling techniques. Practical implications The results of this study are useful for government officials especially those related to the ministry of health care and public health organizations of various countries, who usually invest in co-designing authentic, reliable and high interactive online information-sharing websites. Social implications The results of this study are helpful for government officials, especially those related to the ministry of health care and public health organizations of various countries, who usually invest in co-designing authentic, reliable and high interactive online information-sharing websites. Originality/value The study is unique as it provides insight into the opinion of the adolescent students, primarily upon encountering the online mental health information concerning the Indian perspective. Future researchers, health-care policymakers and health-care professionals may use the study to capture a complete picture of a relevant phenomenon in their work.
Article
Purpose The experiences of clinical facilitators working within non-conventional mental health settings have not yet been explored. The purpose of this paper is to explore the experiences of clinical facilitators when facilitating nursing student learning within a non-conventional mental health clinical placement. Design/methodology/approach This study adopted a qualitative phenomenological approach. The participants in this study were five registered nurses who had facilitated students at a non-conventional mental health clinical placement called Recovery Camp. Individual in-depth interviews were conducted. Findings The facilitators experiences could be understood through two main themes: facilitator skills and opportunities for student learning. Recovery Camp allowed the facilitators to build on their own nursing and facilitation skills, while examining themselves as a mental health nurse. “Being with” students (immersive engagement) enabled opportunistic and rare learning moments. Originality/value To the best of the authors’ knowledge, this is the first known study to explore the experiences of clinical facilitators working in a non-conventional mental health placement.
Article
Family caregiving scholars recommend that health providers receive competency‐based education to partner with and support family caregivers to care and to maintain their own health. While it may be relatively easy to develop competency‐based education for healthcare providers, ensuring widespread uptake and spread and scale of healthcare education is critical to ensuring consistent person‐centered support for all family caregivers (FCGs) throughout the care trajectory. The development of novel healthcare innovations requires implementation strategies for uptake and spread, with implementation involving the use of strategies to integrate a novel innovation into healthcare. Research suggests that there are many factors involved in successful implementation and a synthesis of potential factors is warranted. The purpose of this review is to provide an in‐depth examination of facilitators, barriers and considerations for implementation of a novel healthcare innovation that will be used to develop an implementation plan for spread and scale of our competency‐based education for health providers to learn about person‐centered care for FCGs. A systematic review of published and grey literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA [Moher et al., 2015]) guidelines. The systematic review involved searching four databases for original research articles that described barriers, facilitators and/or other considerations when implementing innovations. Twenty‐eight articles were included in the qualitative thematic analyses and described three areas of implementation research: barriers, facilitators and recommendations. There were major and parallel themes that emerged under facilitators and barriers. There were a wide variety of strategies that were identified as recommendations. The findings were synthesised into five considerations for implementation: Research and information sharing, intentional implementation planning, organisational underpinnings, creating the clinical context and facilitative training. This review provides an integrative overview of identified facilitators, barriers and recommendations for implementation that may aid in developing implementation strategies that can be tailored to the local context or innovation being implemented.
Article
Few cancer patients receive guideline-concordant care for treatment of tobacco dependence. The purpose of this pilot trial was to obtain preliminary estimates of effectiveness of an evidence-based practice intervention on the delivery of tobacco treatment and cessation outcomes in cancer patients. We conducted a pragmatic implementation trial with a before-after design in 119 current or recently quit adult smokers with cancer who met with a clinician at a single National Cancer Institute designated comprehensive cancer center (CCC) (n = 61 pre-implementation, n = 58 post-implementation). We used a multi-component strategy based on the Chronic Care Model to implement National Comprehensive Cancer Network (NCCN) guidelines for smoking cessation. Smoking cessation counseling during the index visit was assessed by exit interview and patients were interviewed by phone to assess cessation outcomes at 3-month follow-up. Performance of cessation counseling and 7-day point prevalence abstinence (PPA) were compared across the pre- and post-implementation periods using log-logistic regression, accounting for clustering by nursing staff. More patients had received assistance in quitting at the index visit during the post-implementation period compared to the pre-implementation period (30 vs. 10%, p < .01). At 3-month follow-up, 38 and 14% of participants had discussed smoking cessation medication with a CCC healthcare professional and 57 and 27% of participants had used pharmacotherapy, respectively (p < .01 for both comparisons). Seven-day PPA at 3-month follow-up was similar in both periods, however (14 vs. 12%, respectively). A multi-component tobacco treatment intervention increased the proportion of smokers who received assistance in quitting smoking during usual cancer care but did not improve cessation outcomes.
Article
Aim To evaluate an emancipatory Practice Development approach for strengthening nursing surveillance on a single medical-surgical ward. Background Registered nurses keep patients safe in acute care settings through the complex process of nursing surveillance. Our interest was understanding how frontline teams can build safety cultures that enable proactive nursing surveillance in acute care wards. Design A year-long emancipatory Practice Development project. Methods A collaborative relationship was established around a shared interest of nursing surveillance capacity and researcher embedded on a medical-surgical ward. Critical analysis of workplace observations and reflection with staff generated key sites for collective action. Ward engagement was supported by creative Practice Development methods including holistic facilitation, critical reflection and action learning. An action learning set was established with a group of clinical nurses, facilitating practitioner-led change initiatives which strengthened nursing surveillance and workplace learning. Evaluation supported an iterative approach, building on what worked in an acute care context. Immersive researcher evaluation, drawing on multiple data sources, generated an analysis of how ward nursing surveillance capacity can be strengthened. COREQ criteria guided reporting. Results The ward moved through a turbulent and transformative process of resistance and retreat towards a new learning culture where nursing surveillance was visible and valued. Staff developed and sustained innovations including the ‘My MET Call series’, a ‘Shared GCS initiative’, an enhanced ‘Team Safety Huddle’, and staff-led Practice Development workshops. These new practices affirmed nurses’ agency, asserted nurses’ clinical knowledge, positioned nurses to participate in team decision-making and humanised care. Conclusion Working collaboratively with frontline staff enabled bottom-up sustainable innovation to strengthen nursing surveillance capacity where it mattered most, at the point of care. Relevance to clinical practice Emancipatory Practice Development enables the profound impact of small-scale, microsystem level practice transformation. It is an accessible methodology for clinical teams to develop effective workplace cultures.
Article
Evidence-based practice is often not implemented in nursing for reasons relating to leadership. This article aims to cast light on the factors that facilitate nursing evidence implementation perceived by nurse managers in their practical experiences of this implementation. It is a qualitative, narrative metasynthesis of primary studies on nurse managers’ leadership-related facilitation experiences, following the Joanna Briggs Institute meta-aggregative approach and the Promoting Action on Research Implementation in Health Services (PARiHS) model. Eleven primary studies were included and three general categories were identified as leadership-related factors facilitating evidence implementation: teamwork (communication between managers and staff nurses), organizational structures (strategic governance), and transformational leadership (influence on evidence application and readiness for change among leaders). Nurse managers act as facilitators of evidence-based practices by transforming contexts to motivate their staff and move toward a shared vision of change. Always providing support as managers and colleagues, sharing their experience in the clinic environment.
Article
The World Health Organization (WHO) recommends tuberculosis preventive treatment (TPT) in people with HIV (PWH), yet implementation remains poor, especially in rural communities. We examined factors influencing TPT initiation in PWH on antiretroviral therapy (ART) in rural South Africa using the Promoting Action on Research Implementation in Health Services (PARiHS) framework to identify contextual factors and facilitation strategies to successfully implement TPT. Patient and clinical factors were extracted from medical records at two primary healthcare clinics (PHCs). Among 455 TPT eligible indivdiuals, only 263 (57.8%) initiated TPT. Patient-level characteristics (older age and symptoms of fever or weight loss) were significantly associated with TPT initiation in bivariate analysis, but PHC was the only independent correlate of TPT initiation (aOR: 2.24; 95% CI: 1.49-3.38). Clinic-level factors are crucial targets for implementing TPT to reduce the burden of HIV-associated TB. Gaps in knowledge of HCW, staff shortages, and non-integrated HIV/TB services were identified barriers to TPT implementation. Evidence-based strategies for facilitating TPT implementation that might be under-prioritized include ongoing reprioritization, expanding training for primary care providers, and quality improvement strategies (organisational changes, multidisciplinary teams, and monitoring and feedback). Addressing contextual barriers through these facilitation strategies may improve future TPT implementation in this setting.
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Background Ethnographic approaches offer a method and a way of thinking about implementation. This manuscript applies a specific case study method to describe the impact of the longitudinal interplay between implementation stakeholders. Growing out of science and technology studies (STS) and drawing on the latent archaeological sensibilities implied by ethnographic methods, the STS case-study is a tool for implementors to use when a piece of material culture is an essential component of an innovation. Methods We conducted an ethnographic process evaluation of the clinical implementation of tele-critical care (Tele-CC) services in the Department of Veterans Affairs. We collected fieldnotes and conducted participant observation at virtual and in-person education and planning events (n = 101 h). At Go-Live and 6-months post-implementation, we conducted site visits to the Tele-CC hub and 3 partnered ICUs. We led semi-structured interviews with ICU staff at Go-Live (43 interviews with 65 participants) and with ICU and Tele-CC staff 6-months post-implementation (44 interviews with 67 participants). We used verification strategies, including methodological coherence, appropriate sampling, collecting and analyzing data concurrently, and thinking theoretically, to ensure the reliability and validity of our data collection and analysis process. Results The STS case-study helped us realize that we must think differently about how a Tele-CC clinician could be noticed moving from communal to intimate space. To understand how perceptions of surveillance impacted staff acceptance, we mapped the materials through which surveillance came to matter in the stories staff told about cameras, buttons, chimes, motors, curtains, and doorbells. Conclusions STS case-studies contribute to the literature on longitudinal qualitive research (LQR) in implementation science, including pen portraits and periodic reflections. Anchored by the material, the heterogeneity of an STS case-study generates questions and encourages exploring differences. Begun early enough, the STS case-study method, like periodic reflections, can serve to iteratively inform data collection for researchers and implementors. The next step is to determine systematically how material culture can reveal implementation barriers and direct attention to potential solutions that address tacit, deeply rooted challenges to innovations in practice and technology.
Article
Background Implementation factors are hypothesised to moderate the implementation of innovations. Although individual barriers and facilitators have been identified for the implementation of different evidence-based services in pharmacy, relationships between implementation factors are usually not considered. Objectives To examine how a network of implementation factors and the position of each factor within this network structure influences the implementation of a medication review service in community pharmacy. Methods A mixed methods approach was used. Medication review with follow-up service was the innovation to be implemented over 12 months in community pharmacies. A network analysis to model relationships between implementation factors was undertaken. Two networks were created. Results Implementation factors hindering the service implementation with the highest centrality measures were time, motivation, recruitment, individual identification with the organization and personal characteristics of the pharmacists. Three hundred and sixty-nine different interrelationships between implementation factors were identified. Important causal relationships between implementation factors included: workflow-time; characteristics of the pharmacy-time; personal characteristics of the pharmacists-motivation. Implementation factors facilitating the implementation of the service with highest centrality scores were motivation, individual identification with the organization, beliefs, adaptability, recruitment, external support and leadership. Four hundred and fifty-six different interrelationships were identified. The important causal relationships included: motivation-external support; structure-characteristics of the pharmacy; demographics-location of the pharmacy. Conclusion Network analysis has proven to be a useful technique to explore networks of factors moderating the implementation of a pharmacy service. Relationships were complex with most implementation factors being interrelated. Motivation and individual identification with the organisation seemed critical factors in both hindering and facilitating the service implementation. The results can inform the design of implementation programs and tailored strategies to promote faster implementation of innovations in pharmacy.
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This chapter describes Roadmap, a comprehensive planned action framework that can be used to guide implementation planning, implementation, evaluation, and sustainability. Roadmap breaks down the implementation process into manageable components and identifies what data and actions are required to proceed at each stage of the process. The three phases of Roadmap are: (i) Issue Identification and Clarification, (ii) Build Solutions and Field Test Them, and (iii) Implement, Evaluate and Sustain.
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The book was first published in 1994 and reprinted in 1994, 1995 (twice) and 1996 (twice).
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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 ($A142/doctor) was 24 times that of the mailed approach. The volunteer courier approach ($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.
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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.
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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.
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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.
Article
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.
Article
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.
Article
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)
Article
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
Article
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.
Article
• 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.
Article
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.
Article
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.
Article
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)
Article
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 …
Article
•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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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;
Article
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.
Article
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.
Article
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.