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  • 1.
    Aarons, Gregory
    et al.
    Univ Calif San Diego, La Jolla, CA 92093 USA.;Child & Adolescent Serv Res Ctr, San Diego, CA USA..
    Green, Amy
    Univ Calif San Diego, La Jolla, CA 92093 USA..
    Moullin, Joanna
    Univ Calif San Diego, La Jolla, CA 92093 USA.;Univ Technol Sydney, Sydney, NSW, Australia..
    Ehrhart, Mark
    San Diego State Univ, San Diego, CA 92182 USA.;Univ Cent Florida, Orlando, FL 32816 USA..
    Ducarroz, Simon
    Ctr Reg Prevent Canc, Ctr Hygee, St Priest En Jarez, France..
    Sevdalis, Nick
    Kings Coll London, London, England..
    Hasson, Henna
    Karolinska Inst, Stockholm, Sweden.;Stockholm Cty Council, Ctr Epidemiol & Community Med, Stockholm, Sweden..
    von Thiele Schwarz, Ulrica
    Mälardalen University, School of Health, Care and Social Welfare. Karolinska Inst, Stockholm, Sweden.
    James, Sigrid
    Univ Kassel, Kassel, Germany..
    Willging, Cathleen
    Pacific Inst Res & Evaluat, Behav Hlth Res Ctr Southwest, Albuquerque, NM USA..
    Fostering international collaborations in implementation science2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13Article in journal (Other academic)
  • 2.
    Algurén, Beatrix
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Food and Nutrition and Sport Science, University of Gothenburg, Faculty of Education, Gothenburg, Sweden.
    Nordin, Annika
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Futurum, Region Jönköping County, Jönköping, Sweden.
    Peterson, Anette
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Futurum, Region Jönköping County, Jönköping, Sweden.
    In-depth comparison of two quality improvement collaboratives from different healthcare areas based on registry data - Possible factors contributing to sustained improvement in outcomes beyond the project time2019In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 14, no 1, article id 74Article in journal (Refereed)
    Abstract [en]

    Background: Quality improvement collaboratives (QICs) are widely used to improve healthcare, but there are few studies of long-term sustained improved outcomes, and inconsistent evidence about what factors contribute to success. The aim of the study was to open the black box of QICs and compare characteristics and activities in detail of two differing QICs in relation to their changed outcomes from baseline and the following 3 years.

    Methods: Final reports of two QICs - one on heart failure care with five teams, and one on osteoarthritis care with seven teams, including detailed descriptions of improvement projects from each QIC's team, were analysed and coded by 18 QIC characteristics and four team characteristics. Goal variables from each team routinely collected within the Swedish Heart Failure Registry (SwedeHF) and the Better Management of Patients with OsteoArthritis Registry (BOA) at year 2013 (baseline), 2014, 2015 and 2016 were analysed with univariate statistics.

    Results: The two QICs differed greatly in design. The SwedeHF-QIC involved eight experts and ran for 12 months, whereas the BOA-QIC engaged three experts and ran for 6 months. There were about twice as many activities in the SwedeHF-QIC as in the BOA-QIC and they ranged from standardisation of team coordination to better information and structured follow-ups. The outcome results were heterogeneous within teams and across teams and QICs. Both QICs were highly appreciated by the participants and contributed to their learning, e.g. of improvement methods; however, several teams had already reached goal values when the QICs were launched in 2013.

    Conclusions: Even though many QI activities were carried out, it was difficult to see sustained improvements on outcomes. Outcomes as specific measurable aspects of care in need of improvement should be chosen carefully. Activities focusing on adherence to standard care programmes and on increased follow-up of patients seemed to lead to more long-lasting improvements. Although earlier studies showed that data follow-up and measurement skills as well as well-functioning data warehouses contribute to sustained improvements, the present registries' functionality and QICs at this time did not support those aspects sufficiently. Further studies on QICs and their impact on improvement beyond the project time should investigate the effect of those elements in particular. 

  • 3.
    Bergström, Anna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Namusoko, Sarah
    School of Public Health, Makerere University College of Health Sciences, New Mulago Hospital Complex, Uganda.
    Waiswa, Peter
    Department of Public Health Sciences, Division of Global Health (IHCAR), Karolinska Institutet, Sweden.
    Wallin, Lars
    Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Sweden.
    Knowledge translation in Uganda: a qualitative study of Ugandan midwives' and managers' perceived relevance of the sub-elements of the context cornerstone in the PARIHS framework2012In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 7, no 1, p. 117-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    A large proportion of the annual 3.3 million neonatal deaths could be averted if there was a high uptake of basic evidence-based practices. In order to overcome this 'know-do' gap, there is an urgent need for in-depth understanding of knowledge translation (KT). A major factor to consider in the successful translation of knowledge into practice is the influence of organizational context. A theoretical framework highlighting this process is Promoting Action on Research Implementation in Health Services (PARIHS). However, research linked to this framework has almost exclusively been conducted in high-income countries. Therefore, the objective of this study was to examine the perceived relevance of the subelements of the organizational context cornerstone of the PARIHS framework, and also whether other factors in the organizational context were perceived to influence KT in a specific low-income setting.

    METHODS:

    This qualitative study was conducted in a district of Uganda, where focus group discussions and semi-structured interviews were conducted with midwives (n = 18) and managers (n = 5) within the catchment area of the general hospital. The interview guide was developed based on the context sub-elements in the PARIHS framework (receptive context, culture, leadership, and evaluation). Interviews were transcribed verbatim, followed by directed content analysis of the data.

    RESULTS:

    The sub-elements of organizational context in the PARIHS framework--i.e., receptive context, culture, leadership, and evaluation--also appear to be relevant in a low-income setting like Uganda, but there are additional factors to consider. Access to resources, commitment and informal payment, and community involvement were all perceived to play important roles for successful KT.

    CONCLUSIONS:

    In further development of the context assessment tool, assessing factors for successful implementation of evidence in low-income settings--resources, community involvement, and commitment and informal payment--should be considered for inclusion. For low-income settings, resources are of significant importance, and might be considered as a separate subelement of the PARIHS framework as a whole.

  • 4.
    Bergström, Anna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Skeen, Sarah
    Duc, Duong M.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Blandon, Elmer Zelaya
    Estabrooks, Carole
    Gustavsson, Petter
    Hoa, Dinh Thi Phuong
    Kallestal, Carina
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Nga, Nguyen Thu
    Persson, Lars-Åke
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Pervin, Jesmin
    Peterson, Stefan Swartling
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Rahman, Anisur
    Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Squires, Janet E.
    Tomlinson, Mark
    Waiswa, Peter
    Wallin, Lars
    Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings2015In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 10, article id 120Article in journal (Refereed)
    Abstract [en]

    Background: The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose. Methods: The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries. Results: The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge. Conclusions: Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs.

  • 5. Bergström, Anna
    et al.
    Skeen, Sarah
    Duc, Duong M.
    Blandon, Elmer Zelaya
    Estabrooks, Carole
    Gustavsson, Petter
    Hoa, Dinh Thi Phuong
    Kallestål, Carina
    Malqvist, Mats
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska Institutet.
    Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings2015In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 10, article id 120Article in journal (Refereed)
    Abstract [en]

    Background: The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose.

    Methods: The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries.

    Results: The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge.

    Conclusions: Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs.

  • 6.
    Boström, Anne-Marie
    et al.
    Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet.
    Nilsson Kajermo, Kerstin
    Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet and Clinical Research Utilization (CRU), Karolinska University Hospital.
    Nordström, Gun
    Karlstad University, Faculty of Social and Life Sciences, Department of Nursing.
    Wallin, Lars
    Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet and Clinical Research Utilization (CRU), Karolinska University Hospital.
    Barriers to research utilization and research use among registered nurses working in the care of older people. Does the BARRIERS Scale discriminate between research users and non-research uses on perception of barriers?2008In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 3, no 24Article in journal (Refereed)
    Abstract [en]

    BackgroundOne strategy to enhance research use and change current practice is to identify barriers and then implement tailored interventions to reduce these barriers. In nursing, the BARRIERS scale has been frequently used to identify nurses' perceptions of barriers to research utilization. However, this scale has not been applied to care of older people, and only one study has investigated how identified barriers link to research utilization. Therefore, the purpose of this study was twofold: to describe RNs' perceptions of barriers to and facilitators of research utilization and to examine the validity of the BARRIERS scale in relation to research use.

    MethodsA cross-sectional survey design was used and registered nurses (RNs) working in the care of older people participated (response rate 67%, n = 140/210). Two questionnaires, the BARRIERS scale and the Research Utilization Questionnaire (RUQ), were used. Data were analyzed using descriptive and bivariate inferential statistics.

    ResultsCharacteristics of the organization and the presentation of research findings were rated as the most prominent barriers. The three items most frequently reported as barriers were: the nurse is isolated from knowledgeable colleagues with whom to discuss the research (89%); the facilities are inadequate for implementation (88%); and, the relevant literature is not compiled in one place (81%). Surveyed RNs suggested more support from unit managers and better availability of user-friendly reports in Swedish to enhance research use.

    The RNs reported a modest use of research. A weak but significant correlation was found between the Research Use index in RUQ and the Presentation subscale in the BARRIERS scale (r = -0.289, p < 0.01), suggesting that the RNs reporting more research use were less likely to perceive presentation of research as a barrier. Dividing the sample into research users (n = 29) and non-research users (n = 105), the research users rated significantly lower on the subscales Presentation, Nurse and Research in the BARRIERS scale.

    ConclusionThe BARRIERS scale revealed differences in the perception of barriers between research users and non-research users. Thus, methodologically the scale appears useful in identifying some types of barriers to research utilization but not organizational barriers. The identified barriers, however, are general and wide-ranging, making it difficult to design useful specific interventions.

  • 7.
    Brantnell, Anders
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Psychology in Healthcare.
    Baraldi, Enrico
    Uppsala University, Disciplinary Domain of Science and Technology, Technology, Department of Engineering Sciences, Industrial Engineering & Management.
    van Achterberg, Theo
    KU Leuven.
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Research funders’ roles and perceived responsibilities in relation to the implementation of clinical research results: a multiple case study of Swedish research funders2015In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 10, article id 100Article in journal (Refereed)
    Abstract [en]

    Background

    Implementation of clinical research results is challenging, yet the responsibility for implementation is seldom addressed. The process from research to the use of clinical research results in health care can be facilitated by research funders. In this paper, we report the roles of ten Swedish research funders in relation to implementation and their views on responsibilities in implementation.

    Findings

    Ten cases were studied and compared using semi-structured interviews. In addition, websites and key documents were reviewed. Eight facilitative roles for research funders in relation to the implementation of clinical research results were identified. Three of them were common for several funders: “Advocacy work,” “Monitoring implementation outcomes,” and “Dissemination of knowledge.” Moreover, the research funders identified six different actors responsible for implementation, five of which belonged to the healthcare setting. Collective and organizational responsibilities were the most common forms of responsibilities among the identified actors responsible for implementation.

    Conclusions

    The roles commonly identified by the Swedish funders, “Advocacy work,” “Monitoring implementation outcomes,” and “Dissemination of knowledge,” seem feasible facilitative roles in relation to the implementation of clinical research results. However, many actors identified as responsible for implementation together with the fact that collective and organizational responsibilities were the most common forms of responsibilities entail a risk of implementation becoming no one’s responsibility. 

  • 8.
    Carlfjord, Siw
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Five years experience of an annual course on implementation science: an evaluation among course participants2017In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 12, article id 101Article in journal (Refereed)
    Abstract [en]

    Background: Increasing interest in implementation science has generated a demand for education and training opportunities for researchers and practitioners in the field. However, few implementation science courses have been described or evaluated in the scientific literature. The aim of the present study was to provide a short-and long-term evaluation of the implementation training at Linkoping University, Sweden. Methods: Two data collections were carried out. In connection with the final seminar, a course evaluation form, including six items on satisfaction and suggestions for improvement, was distributed to the course participants, a total of 101 students from 2011 to 2015 (data collection 1), response rate 72%. A questionnaire including six items was distributed by e-mail to the same students in autumn 2016 (data collection 2), response rate 63%. Data from the two data collections were presented descriptively and analysed using the Kirkpatrick model consisting of four levels: reaction, learning, behaviour and results. Results: The students were very positive immediately after course participation, rating high on overall perception of the course and the contents (reaction). The students also rated high on achievement of the course objectives and considered their knowledge in implementation science to be very good and to a high degree due to course participation (learning). Knowledge gained from the course was viewed to be useful (behaviour) and was applied to a considerable extent in research projects and work apart from research activities (results). Conclusions: The evaluation of the doctoral-level implementation science course provided by Linkoping University showed favourable results, both in the short and long term. The adapted version of the Kirkpatrick model was useful because it provided a structure for evaluation of the short-and long-term learning outcomes.

  • 9.
    Dannapfel, Petra
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
    Peolsson, Anneli
    Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis.
    What supports physiotherapists’ use of research in clinical practice? A qualitative study in Sweden2013In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 8Article in journal (Refereed)
    Abstract [en]

    Background

    Evidence-based practice has increasingly been recognized as a priority by professional physiotherapy organizations and influential researchers and clinicians in the field. Numerous studies in the past decade have documented that physiotherapists hold generally favorable attitudes to evidence-based practice and recognize the importance of using research to guide their clinical practice. Research has predominantly investigated barriers to research use. Less is known about the circumstances that actually support use of research by physiotherapists. This study explores the conditions at different system levels that physiotherapists in Sweden perceive to be supportive of their use of research in clinical practice.

    Methods

    Patients in Sweden do not need a referral from a physician to consult a physiotherapist and physiotherapists are entitled to choose and perform any assessment and treatment technique they find suitable for each patient. Eleven focus group interviews were conducted with 45 physiotherapists, each lasting between 90 and 110 minutes. An inductive approach was applied, using topics rather than questions to allow the participants to generate their own questions and pursue their own priorities within the framework of the aim. The data were analyzed using qualitative content analysis.

    Results

    Analysis of the data yielded nine favorable conditions at three system levels supporting the participant’s use of research in clinical practice: two at the individual level (attitudes and motivation concerning research use; research-related knowledge and skills), four at the workplace level (leadership support; organizational culture; research-related resources; knowledge exchange) and three at the extra-organizational level (evidence-based practice guidelines; external meetings, networks, and conferences; academic research and education).

    Conclusions

    Supportive conditions for physiotherapists’ use of research exist at multiple interdependent levels, including the individual, workplace, and extra-organizational levels. Research use in physiotherapy appears to be an interactive and interpretative social process that involves a great deal of interaction with various people, including colleagues and patients.

  • 10.
    Elf, Marie
    et al.
    School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
    Nordmark, Sofi
    Luleå University of Technology, Department of Health Sciences, Nursing Care.
    Lyhagen, Johan
    Department of Statistics, Uppsala University, Uppsala, Sweden.
    Finch, Tracy
    Department of Nursing, Midwifery & Health, Faculty of Health & Life Sciences, Northumbria University, Newcastle upon Tyne, UK. .
    Åberg, Anna Christina
    School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
    The Swedish version of the Normalization Process Theory Measure S-NoMAD: translation, adaptation, and pilot testing2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, no 1, article id 146Article in journal (Refereed)
    Abstract [en]

    Background

    The original British instrument the Normalization Process Theory Measure (NoMAD) is based on the four core constructs of the Normalization Process Theory: Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring. They represent ways of thinking about implementation and are focused on how interventions can become part of everyday practice.

    Aim

    To translate and adapt the original NoMAD into the Swedish version S-NoMAD and to evaluate its psychometric properties based on a pilot test in a health care context including in-hospital, primary, and community care contexts.

    Methods

    A systematic approach with a four-step process was utilized, including forward and backward translation and expert reviews for the test and improvement of content validity of the S-NoMAD in different stages of development. The final S-NoMAD version was then used for process evaluation in a pilot study aimed at the implementation of a new working method for individualized care planning. The pilot was executed in two hospitals, four health care centres, and two municipalities in a region in northern Sweden. The S-NoMAD pilot results were analysed for validity using confirmatory factor analysis, i.e. a one-factor model fitted for each of the four constructs of the S-NoMAD. Cronbach’s alpha was used to ascertain the internal consistency reliability.

    Results

    In the pilot, S-NoMAD data were collected from 144 individuals who were different health care professionals or managers. The initial factor analysis model showed good fit for two of the constructs (Coherence and Cognitive Participation) and unsatisfactory fit for the remaining two (Collective Action and Reflexive Monitoring) based on three items. Deleting those items from the model yielded a good fit and good internal consistency (alphas between 0.78 and 0.83). However, the estimation of correlations between the factors showed that the factor Reflexive Monitoring was highly correlated (around 0.9) with the factors Coherence and Collective Action.

    Conclusions

    The results show initial satisfactory psychometric properties for the translation and first validation of the S-NoMAD. However, development of a highly valid and reliable instrument is an iterative process, requiring more extensive validation in various settings and populations. Thus, in order to establish the validity and reliability of the S-NoMAD, additional psychometric testing is needed.

  • 11.
    Elf, Marie
    et al.
    Dalarna Univ, Sch Educ Hlth & Social Studies, Falun, Sweden;Karolinska Inst, Dept Neurobiol Care Sci & Soc, Stockholm, Sweden.
    Nordmark, Sofi
    Lulea Univ Technol, Dept Hlth Sci, Lulea, Sweden.
    Lyhagen, Johan
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Lindberg, Inger
    Lulea Univ Technol, Dept Hlth Sci, Lulea, Sweden.
    Finch, Tracy
    Northumbria Univ, Fac Hlth & Life Sci, Dept Nursing Midwifery & Hlth, Newcastle Upon Tyne, Tyne & Wear, England.
    Åberg, Anna Cristina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Geriatrics. Dalarna Univ, Sch Educ Hlth & Social Studies, Falun, Sweden.
    The Swedish version of the Normalization Process Theory Measure S-NoMAD: translation, adaptation, and pilot testing2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 146Article in journal (Refereed)
    Abstract [en]

    BackgroundThe original British instrument the Normalization Process Theory Measure (NoMAD) is based on the four core constructs of the Normalization Process Theory: Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring. They represent ways of thinking about implementation and are focused on how interventions can become part of everyday practice.AimTo translate and adapt the original NoMAD into the Swedish version S-NoMAD and to evaluate its psychometric properties based on a pilot test in a health care context including in-hospital, primary, and community care contexts.MethodsA systematic approach with a four-step process was utilized, including forward and backward translation and expert reviews for the test and improvement of content validity of the S-NoMAD in different stages of development. The final S-NoMAD version was then used for process evaluation in a pilot study aimed at the implementation of a new working method for individualized care planning. The pilot was executed in two hospitals, four health care centres, and two municipalities in a region in northern Sweden. The S-NoMAD pilot results were analysed for validity using confirmatory factor analysis, i.e. a one-factor model fitted for each of the four constructs of the S-NoMAD. Cronbach's alpha was used to ascertain the internal consistency reliability.ResultsIn the pilot, S-NoMAD data were collected from 144 individuals who were different health care professionals or managers. The initial factor analysis model showed good fit for two of the constructs (Coherence and Cognitive Participation) and unsatisfactory fit for the remaining two (Collective Action and Reflexive Monitoring) based on three items. Deleting those items from the model yielded a good fit and good internal consistency (alphas between 0.78 and 0.83). However, the estimation of correlations between the factors showed that the factor Reflexive Monitoring was highly correlated (around 0.9) with the factors Coherence and Collective Action.ConclusionsThe results show initial satisfactory psychometric properties for the translation and first validation of the S-NoMAD. However, development of a highly valid and reliable instrument is an iterative process, requiring more extensive validation in various settings and populations. Thus, in order to establish the validity and reliability of the S-NoMAD, additional psychometric testing is needed.

  • 12.
    Elf, Marie
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Nordmark, Sofi
    Lyhagen, Johan
    Lindberg, Inger
    Finch, Tracy
    Åberg, Anna Cristina
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Uppsala universitet.
    The Swedish version of the Normalization Process Theory Measure S-NoMAD: translation, adaptation, and pilot testing2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, no 1, article id 146Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The original British instrument the Normalization Process Theory Measure (NoMAD) is based on the four core constructs of the Normalization Process Theory: Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring. They represent ways of thinking about implementation and are focused on how interventions can become part of everyday practice.

    AIM: To translate and adapt the original NoMAD into the Swedish version S-NoMAD and to evaluate its psychometric properties based on a pilot test in a health care context including in-hospital, primary, and community care contexts.

    METHODS: A systematic approach with a four-step process was utilized, including forward and backward translation and expert reviews for the test and improvement of content validity of the S-NoMAD in different stages of development. The final S-NoMAD version was then used for process evaluation in a pilot study aimed at the implementation of a new working method for individualized care planning. The pilot was executed in two hospitals, four health care centres, and two municipalities in a region in northern Sweden. The S-NoMAD pilot results were analysed for validity using confirmatory factor analysis, i.e. a one-factor model fitted for each of the four constructs of the S-NoMAD. Cronbach's alpha was used to ascertain the internal consistency reliability.

    RESULTS: In the pilot, S-NoMAD data were collected from 144 individuals who were different health care professionals or managers. The initial factor analysis model showed good fit for two of the constructs (Coherence and Cognitive Participation) and unsatisfactory fit for the remaining two (Collective Action and Reflexive Monitoring) based on three items. Deleting those items from the model yielded a good fit and good internal consistency (alphas between 0.78 and 0.83). However, the estimation of correlations between the factors showed that the factor Reflexive Monitoring was highly correlated (around 0.9) with the factors Coherence and Collective Action.

    CONCLUSIONS: The results show initial satisfactory psychometric properties for the translation and first validation of the S-NoMAD. However, development of a highly valid and reliable instrument is an iterative process, requiring more extensive validation in various settings and populations. Thus, in order to establish the validity and reliability of the S-NoMAD, additional psychometric testing is needed.

  • 13.
    Eriksson, Leif
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Nga, Nguyen Thu
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Hoa, Dinh P.
    Hanoi School of Public Health, Hanoi, Vietnam.
    Persson, Lars-Åke
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Pediatrics.
    Wallin, Lars
    Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet and Clinical Research Utilization (CRU), Karolinska University Hospital, Stockholm, Sweden.
    Newborn care and knowledge translation - perceptions among primary health care staff in northern Vietnam2011In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 6, p. 29-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Nearly four million neonatal deaths occur annually in the world despite existing evidence-based knowledge with the potential to prevent many of these deaths. Effective knowledge translation (KT) could help to bridge this know-do gap in global health. The aim of this study was to explore aspects of KT at the primary healthcare level in a northern province in Vietnam. METHODS: Six focus-group discussions were conducted with primary healthcare staff members who provided neonatal care in districts that represented three types of geographical areas existing in the province (urban, rural, and mountainous). Recordings were transcribed verbatim, translated into English, and analyzed using content analysis. RESULTS: We identified three main categories of importance for KT. Healthcare staff used several channels for acquisition and management of knowledge (1), but none appeared to work well. Participants preferred formal training to reading guideline documents, and they expressed interest in interacting with colleagues at higher levels, which rarely happened. In some geographical areas, traditional medicine (2) seemed to compete with evidence-based practices, whereas in other areas it was a complement. Lack of resources, low frequency of deliveries and, poorly paid staff were observed barriers to keeping skills at an adequate level in the healthcare context (3). CONCLUSIONS: This study indicates that primary healthcare staff work in a context that to some extent enables them to translate knowledge into practice. However, the established and structured healthcare system in Vietnam does constitute a base where such processes could be expected to work more effectively. To accelerate the development, thorough considerations over the current situation and carefully targeted actions are required.

  • 14.
    Forsman, Henrietta
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Rudman, Ann
    Gustavsson, Petter
    Ehrenberg, Anna
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Nurses' research utilization two years after graduation: a national survey ofassociated individual, organizational, and educational factors2012In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 7, article id 46Article in journal (Refereed)
    Abstract [en]

    Background. Nurses' research utilization (RU) as part of evidence-based practice is strongly emphasized in today's nursing education and clinical practice. The primary aim of RU is to provide high-quality nursing care to patients. Data on newly graduated nurses' RU are scarce, but a predominance of low use has been reported in recent studies. Factors associated with nurses' RU have previously been identified among individual and organizational/contextual factors, but there is a lack of knowledge about how these factors, including educational ones, interact with each other and with RU, particularly in nurses during the first years after graduation. The purpose of this study was therefore to identify factors that predict the probability for low RU among registered nurses two years after graduation.

    Methods. Data were collected as part of the LANE study (Longitudinal Analysis of Nursing Education), a Swedish national survey of nursing students and registered nurses. Data on nurses' instrumental, conceptual, and persuasive RU were collected two years after graduation (2007, n = 845), together with data on work contextual factors. Data on individual and educational factors were collected in the first year (2002) and last term of education (2004). Guided by an analytic schedule, bivariate analyses, followed by logistic regression modeling, were applied.

    Results. Of the variables associated with RU in the bivariate analyses, six were found to be significantly related to low RU in the final logistic regression model: work in the psychiatric setting, role ambiguity, sufficient staffing, low work challenge, being male, and low student activity.

    Conclusions. A number of factors associated with nurses' low extent of RU two years postgraduation were found, most of them potentially modifiable. These findings illustrate the multitude of factors related to low RU extent and take their interrelationships into account. This knowledge might serve as useful input in planning future studies aiming to improve nurses', specifically newly graduated nurses', RU.

  • 15.
    Fredriksson, Mio
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Hälso- och sjukvårdsforskning, Sweden.
    Eldh, Ann Catrine
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Hälso- och sjukvårdsforskning, Sweden, Högskolan i Dalarna, Sweden.
    Vengberg, Sofie
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Hälso- och sjukvårdsforskning..
    Dahlström, Tobias
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Hälso- och sjukvårdsforskning, Sweden.
    Halford, Christina
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Hälso- och sjukvårdsforskning, Sweden.
    Wallin, Lars
    Högskolan Dalarna, Sweden, Karolinska Institutet, Sweden.
    Winblad, Ulrika
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Hälso- och sjukvårdsforskning..
    Local politico-administrative perspectives on quality improvement based on national registry data in Sweden: a qualitative study using the Consolidated Framework for Implementation Research.2014In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 9, article id 189Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Through a national policy agreement, over 167 million Euros will be invested in the Swedish National Quality Registries (NQRs) between 2012 and 2016. One of the policy agreement's intentions is to increase the use of NQR data for quality improvement (QI). However, the evidence is fragmented as to how the use of medical registries and the like lead to quality improvement, and little is known about non-clinical use. The aim was therefore to investigate the perspectives of Swedish politicians and administrators on quality improvement based on national registry data.

    METHODS: Politicians and administrators from four county councils were interviewed. A qualitative content analysis guided by the Consolidated Framework for Implementation Research (CFIR) was performed.

    RESULTS: The politicians' and administrators' perspectives on the use of NQR data for quality improvement were mainly assigned to three of the five CFIR domains. In the domain of intervention characteristics, data reliability and access in reasonable time were not considered entirely satisfactory, making it difficult for the politico-administrative leaderships to initiate, monitor, and support timely QI efforts. Still, politicians and administrators trusted the idea of using the NQRs as a base for quality improvement. In the domain of inner setting, the organizational structures were not sufficiently developed to utilize the advantages of the NQRs, and readiness for implementation appeared to be inadequate for two reasons. Firstly, the resources for data analysis and quality improvement were not considered sufficient at politico-administrative or clinical level. Secondly, deficiencies in leadership engagement at multiple levels were described and there was a lack of consensus on the politicians' role and level of involvement. Regarding the domain of outer setting, there was a lack of communication and cooperation between the county councils and the national NQR organizations.

    CONCLUSIONS: The Swedish experiences show that a government-supported national system of well-funded, well-managed, and reputable national quality registries needs favorable local politico-administrative conditions to be used for quality improvement; such conditions are not yet in place according to local politicians and administrators.

  • 16. Fredriksson, Mio
    et al.
    Eldh, Ann Catrine
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Uppsala universitet.
    Vengberg, Sofie
    Dahlström, Tobias
    Halford, Christina
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Winblad, Ulrika
    Local politico-administrative perspectives on quality improvement based on national registry data in Sweden: a qualitative study using the Consolidated Framework for Implementation Research.2014In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 9, article id 189Article in journal (Refereed)
    Abstract [en]

    Background. Through a national policy agreement, over 167 million Euros will be invested in the Swedish National Quality Registries (NQRs) between 2012 and 2016. One of the policy agreement¿s intentions is to increase the use of NQR data for quality improvement (QI). However, the evidence is fragmented as to how the use of medical registries and the like lead to quality improvement, and little is known about non-clinical use. The aim was therefore to investigate the perspectives of Swedish politicians and administrators on quality improvement based on national registry data.

    Methods. Politicians and administrators from four county councils were interviewed. A qualitative content analysis guided by the Consolidated Framework for Implementation Research (CFIR) was performed.

    Results. The politicians and administrators perspectives on the use of NQR data for quality improvement were mainly assigned to three of the five CFIR domains. In the domain of intervention characteristics, data reliability and access in reasonable time were not considered entirely satisfactory, making it difficult for the politico-administrative leaderships to initiate, monitor, and support timely QI efforts. Still, politicians and administrators trusted the idea of using the NQRs as a base for quality improvement. In the domain of inner setting, the organizational structures were not sufficiently developed to utilize the advantages of the NQRs, and readiness for implementation appeared to be inadequate for two reasons. Firstly, the resources for data analysis and quality improvement were not considered sufficient at politico-administrative or clinical level. Secondly, deficiencies in leadership engagement at multiple levels were described and there was a lack of consensus on the politicians¿ role and level of involvement. Regarding the domain of outer setting, there was a lack of communication and cooperation between the county councils and the national NQR organizations.

    Conclusions. The Swedish experiences show that a government-supported national system of well-funded, well-managed, and reputable national quality registries needs favorable local politico-administrative conditions to be used for quality improvement; such conditions are not yet in place according to local politicians and administrators.

  • 17.
    Fredriksson, Mio
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Eldh, Ann
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Vengberg, Sofie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Dahlström, Tobias
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Halford, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Wallin, Lars
    Högskolan Dalarna.
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Local politico-administrative perspectives on quality improvement based on national registry data in Sweden: a qualitative study using the Consolidated Framework for Implementation Research2014In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 9, no 1, p. 189-Article in journal (Refereed)
    Abstract [en]

    Background: Through a national policy agreement, over 167 million Euros will be invested in the Swedish National Quality Registries (NQRs) between 2012 and 2016. One of the policy agreement¿s intentions is to increase the use of NQR data for quality improvement (QI). However, the evidence is fragmented as to how the use of medical registries and the like lead to quality improvement, and little is known about non-clinical use. The aim was therefore to investigate the perspectives of Swedish politicians and administrators on quality improvement based on national registry data.MethodsPoliticians and administrators from four county councils were interviewed. A qualitative content analysis guided by the Consolidated Framework for Implementation Research (CFIR) was performed.ResultsThe politicians¿ and administrators¿ perspectives on the use of NQR data for quality improvement were mainly assigned to three of the five CFIR domains. In the domain of intervention characteristics, data reliability and access in reasonable time were not considered entirely satisfactory, making it difficult for the politico-administrative leaderships to initiate, monitor, and support timely QI efforts. Still, politicians and administrators trusted the idea of using the NQRs as a base for quality improvement. In the domain of inner setting, the organizational structures were not sufficiently developed to utilize the advantages of the NQRs, and readiness for implementation appeared to be inadequate for two reasons. Firstly, the resources for data analysis and quality improvement were not considered sufficient at politico-administrative or clinical level. Secondly, deficiencies in leadership engagement at multiple levels were described and there was a lack of consensus on the politicians¿ role and level of involvement. Regarding the domain of outer setting, there was a lack of communication and cooperation between the county councils and the national NQR organizations.ConclusionsThe Swedish experiences show that a government-supported national system of well-funded, well-managed, and reputable national quality registries needs favorable local politico-administrative conditions to be used for quality improvement; such conditions are not yet in place according to local politicians and administrators.

  • 18.
    Förberg, Ulrika
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Unbeck, Maria
    Karolinska institutet.
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Johansson, Eva
    Petzold, Max
    Ygge, Britt-Marie
    Karolinska institutet.
    Ehrenberg, Anna
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Effects of computer reminders on complications of peripheral venous catheters and nurses' adherence to a guideline in paediatric care: a cluster randomised study2016In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 11, no 1Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Reminder systems in electronic patient records (EPR) have proven to affect both health care professionals' behaviour and patient outcomes. The aim of this cluster randomised trial was to investigate the effects of implementing a clinical practice guideline (CPG) for peripheral venous catheters (PVCs) in paediatric care in the format of reminders integrated in the EPRs, on PVC-related complications, and on registered nurses' (RNs') self-reported adherence to the guideline. An additional aim was to study the relationship between contextual factors and the outcomes of the intervention.

    METHODS: The study involved 12 inpatient units at a paediatric university hospital. The reminders included choice of PVC, hygiene, maintenance, and daily inspection of PVC site. Primary outcome was documented signs and symptoms of PVC-related complications at removal, retrieved from the EPR. Secondary outcome was RNs' adherence to a PVC guideline, collected through a questionnaire that also included RNs' perceived work context, as measured by the Alberta Context Tool. Units were allocated into two strata, based on occurrence of PVCs. A blinded simple draw of lots from each stratum randomised six units to the control and intervention groups, respectively. Units were not blinded. The intervention group included 626 PVCs at baseline and 618 post-intervention and the control group 724 PVCs at baseline and 674 post-intervention. RNs included at baseline were 212 (65.4 %) and 208 (71.5 %) post-intervention.

    RESULTS: No significant effect was found for the computer reminders on PVC-related complications nor on RNs' adherence to the guideline recommendations. The complication rate at baseline and post-intervention was 40.6 % (95 % confidence interval (CI) 36.7-44.5) and 41.9 % (95 % CI 38.0-45.8), for the intervention group and 40.3 % (95 % CI 36.8-44.0) and 46.9 % (95 % CI 43.1-50.7) for the control. In general, RNs' self-rated work context varied from moderately low to moderately high, indicating that conditions for a successful implementation to occur were less optimal.

    CONCLUSIONS: The reminders might have benefitted from being accompanied by a tailored intervention that targeted specific barriers, such as the low frequency of recorded reasons for removal, the low adherence to daily inspection of PVC sites, and the lack of regular feedback to the RNs.

    TRIAL REGISTRATION: Current Controlled Trials ISRCTN44819426.

  • 19.
    Gifford, Wendy A.
    et al.
    Univ Ottawa, Sch Nursing, Fac Hlth Sci, Ottawa, ON, Canada..
    Squires, Janet E.
    Univ Ottawa, Sch Nursing, Fac Hlth Sci, Ottawa, ON, Canada.;Ottawa Hosp Res Inst, Clin Epidemiol Program, Ottawa, ON, Canada..
    Angus, Douglas E.
    Univ Ottawa, Telfer Sch Management, Ottawa, ON, Canada..
    Ashley, Lisa A.
    Canadian Nurses Assoc, Ottawa, ON, Canada..
    Brosseau, Lucie
    Univ Ottawa, Sch Rehabil Sci, Fac Hlth Sci, Ottawa, ON, Canada..
    Craik, Janet M.
    Canadian Assoc Occupat Therapists, Ottawa, ON, Canada..
    Domecq, Marie-Cecile
    Univ Ottawa, Hlth Sci Lib, Ottawa, ON, Canada..
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Göteborgs universitet; Karolinska institutet.
    Wazni, Liquaa
    Univ Ottawa, Sch Nursing, Fac Hlth Sci, Ottawa, ON, Canada..
    Graham, Ian D.
    Univ Gothenburg, Sahlgrenska Acad, Dept Hlth Care Sci, Gothenburg, Sweden.;Univ Ottawa, Sch Epidemiol & Publ Hlth, Ottawa, ON, Canada..
    Managerial leadership for research use in nursing and allied health care professions: a systematic review2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 127Article, review/survey (Refereed)
    Abstract [en]

    Background: Leadership by point-of-care and senior managers is increasingly recognized as critical to the acceptance and use of research evidence in practice. The purpose of this systematic review was to identify the leadership behaviours of managers that are associated with research use by clinical staff in nursing and allied health professionals.

    Methods: A mixed methods systematic review was performed. Eight electronic bibliographic databases were searched. Studies examining the association between leadership behaviours and nurses and allied health professionals' use of research were eligible for inclusion. Studies were excluded if leadership could not be clearly attributed to someone in a management position. Two reviewers independently screened abstracts, reviewed full-text articles, extracted data and performed quality assessments. Narrative synthesis was conducted.

    Results: The search yielded 7019 unique titles and abstracts after duplicates were removed. Three hundred five full-text articles were reviewed, and 31 studies reported in 34 articles were included. Methods used were qualitative (n = 19), cross-sectional survey (n = 9), and mixed methods (n = 3). All studies included nurses, and six also included allied health professionals. Twelve leadership behaviours were extracted from the data for point-of-care managers and ten for senior managers. Findings indicated that managers performed a diverse range of leadership behaviours that encompassed change-oriented, relation-oriented and task-oriented behaviours. The most commonly described behavior was support for the change, which involved demonstrating conceptual and operational commitment to research-based practices.

    Conclusions: This systematic review adds to the growing body of evidence that indicates that manager-staff dyads are influential in translating research evidence into action. Findings also reveal that leadership for research use involves change and task-oriented behaviours that influence the environmental milieu and the organisational infrastructure that supports clinical care. While findings explain how managers enact leadership for research use, we now require robust methodological studies to determine which behaviours are effective in enabling research use with nurses and allied health professionals for high-quality evidence-based care.

  • 20.
    Goicolea, Isabel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Vives-Cases, Carmen
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Marchal, Bruno
    Kegels, Guy
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    How do primary health care teams learn to integrate intimate partner violence (IPV) management? A realist evaluation protocol2013In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 8, p. 36-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite the existence of ample literature dealing, on the one hand, with the integration of innovations within health systems and team learning, and, on the other hand, with different aspects of the detection and management of intimate partner violence (IPV) within healthcare facilities, research that explores how health innovations that go beyond biomedical issues-such as IPV management-get integrated into health systems, and that focuses on healthcare teams' learning processes is, to the best of our knowledge, very scarce if not absent. This realist evaluation protocol aims to ascertain: why, how, and under what circumstances primary healthcare teams engage (if at all) in a learning process to integrate IPV management in their practices; and why, how, and under what circumstances team learning processes lead to the development of organizational culture and values regarding IPV management, and the delivery of IPV management services.

    METHODS: This study will be conducted in Spain using a multiple-case study design. Data will be collected from selected cases (primary healthcare teams) through different methods: individual and group interviews, routinely collected statistical data, documentary review, and observation. Cases will be purposively selected in order to enable testing the initial middle-range theory (MRT). After in-depth exploration of a limited number of cases, additional cases will be chosen for their ability to contribute to refining the emerging MRT to explain how primary healthcare learn to integrate intimate partner violence management.

    DISCUSSION: Evaluations of health sector responses to IPV are scarce, and even fewer focus on why, how, and when the healthcare services integrate IPV management. There is a consensus that healthcare professionals and healthcare teams play a key role in this integration, and that training is important in order to realize changes. However, little is known about team learning of IPV management, both in terms of how to trigger such learning and how team learning is connected with changes in organizational culture and values, and in service delivery. This realist evaluation protocol aims to contribute to this knowledge by conducting this project in a country, Spain, where great endeavours have been made towards the integration of IPV management within the health system.

  • 21.
    Gramlich, Leah M.
    et al.
    Department of Medicine, University of Alberta, Edmonton, Canada; Gastroenterology, Royal Alexandra Hospital, Edmonton AB, Canada.
    Sheppard, Caroline E.
    Department of Surgery, University of Alberta, Edmonton, Canada.
    Wasylak, Tracy
    Alberta Health Services, Edmonton AB, Canada.
    Gilmour, Loreen E.
    Alberta Health Services, Edmonton AB, Canada.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Basualdo-Hammond, Carlota
    Alberta Health Services, Edmonton AB, Canada.
    Nelson, Gregg
    Tom Baker Cancer Centre, Department of Oncology, University of Calgary, Calgary AB, Canada.
    Implementation of Enhanced Recovery After Surgery: a strategy to transform surgical care across a health system2017In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 12, article id 67Article in journal (Refereed)
    Abstract [en]

    Background: Enhanced Recovery After Surgery (ERAS) programs have been shown to have a positive impact on outcome. The ERAS care system includes an evidence-based guideline, an implementation program, and an interactive audit system to support practice change. The purpose of this study is to describe the use of the Theoretic Domains Framework (TDF) in changing surgical care and application of the Quality Enhancement Research Initiative (QUERI) model to analyze end-to-end implementation of ERAS in colorectal surgery across multiple sites within a single health system. The ultimate intent of this work is to allow for the development of a model for spread, scale, and sustainability of ERAS in Alberta Health Services (AHS).

    Methods: ERAS for colorectal surgery was implemented at two sites and then spread to four additional sites. The ERAS Interactive Audit System (EIAS) was used to assess compliance with the guidelines, length of stay, readmissions, and complications. Data sources informing knowledge translation included surveys, focus groups, interviews, and other qualitative data sources such as minutes and status updates. The QUERI model and TDF were used to thematically analyze 189 documents with 2188 quotes meeting the inclusion criteria. Data sources were analyzed for barriers or enablers, organized into a framework that included individual to organization impact, and areas of focus for guideline implementation.

    Results: Compliance with the evidence-based guidelines for ERAS in colorectal surgery at baseline was 40%. Post implementation compliance, consistent with adoption of best practice, improved to 65%. Barriers and enablers were categorized as clinical practice (22%), individual provider (26%), organization (19%), external environment (7%), and patients (25%). In the Alberta context, 26% of barriers and enablers to ERAS implementation occurred at the site and unit levels, with a provider focus 26% of the time, a patient focus 26% of the time, and a system focus 22% of the time.

    Conclusions: Using the ERAS care system and applying the QUERI model and TDF allow for identification of strategies that can support diffusion and sustainment of innovation of Enhanced Recovery After Surgery across multiple sites within a health care system.

  • 22.
    Gurung, Rejina
    et al.
    Golden Community, Jwagal, Lalitpur, Nepal.
    Jha, Anjani Kumar
    Govt Nepal, Minist Hlth & Populat, Kathmandu, Nepal.
    Pyakurel, Susheel
    Nepal Hlth Res Council, Kathmandu, Nepal.
    Gurung, Abhishek
    Golden Community, Jwagal, Lalitpur, Nepal.
    Litorp, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Wrammert, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Jha, Bijay Kumar
    Govt Nepal, Minist Hlth & Populat, Kathmandu, Nepal.
    Paudel, Prajwal
    Anweshan, Lalitpur, Nepal.
    Rahman, Syed Moshfiqur
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Malla, Honey
    Golden Community, Jwagal, Lalitpur, Nepal.
    Sharma, Srijana
    Golden Community, Jwagal, Lalitpur, Nepal.
    Gautam, Manish
    Anweshan, Lalitpur, Nepal.
    Linde, Jorgen Erland
    Stavanger Univ Hosp, Dept Paediat, Stavanger, Norway.
    Moinuddin, Md
    ICDDR B, Maternal & Child Hlth Div, Dhaka, Bangladesh.
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Axelin, Anna
    Univ Turku, Turku, Finland.
    KC, Ashish
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Soc Publ Hlth Phys Nepal, Lalitpur, Nepal.
    Scaling Up Safer Birth Bundle Through Quality Improvement in Nepal (SUSTAIN) - a stepped wedge cluster randomized controlled trial in public hospitals2019In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 14, article id 65Article in journal (Refereed)
    Abstract [en]

    Background: Each year, 2.2 million intrapartum-related deaths (intrapartum stillbirths and first day neonatal deaths) occur worldwide with 99% of them taking place in low- and middle-income countries. Despite the accelerated increase in the proportion of deliveries taking place in health facilities in these settings, the stillborn and neonatal mortality rates have not reduced proportionately. Poor quality of care in health facilities is attributed to two-thirds of these deaths. Improving quality of care during the intrapartum period needs investments in evidence-based interventions. We aim to evaluate the quality improvement packageScaling Up Safer Bundle Through Quality Improvement in Nepal (SUSTAIN)on intrapartum care and intrapartum-related mortality in public hospitals of Nepal.

    Methods: We will conduct a stepped wedge cluster randomized controlled trial in eight public hospitals with each having least 3000 deliveries a year. Each hospital will represent a cluster with an intervention transition period of 2months in each. With a level of significance of 95%, the statistical power of 90% and an intra-cluster correlation of 0.00015, a study period of 19months should detect at least a 15% change in intrapartum-related mortality. Quality improvement training, mentoring, systematic feedback, and a continuous improvement cycle will be instituted based on bottleneck analyses in each hospital. All concerned health workers will be trained on standard basic neonatal resuscitation and essential newborn care. Portable fetal heart monitors (Moyo (R)) and neonatal heart rate monitors (Neobeat (R)) will be introduced in the hospitals to identify fetal distress during labor and to improve neonatal resuscitation. Independent research teams will collect data in each hospital on intervention inputs, processes, and outcomes by reviewing records and carrying out observations and interviews. The dose-response effect will be evaluated through process evaluations.

    Discussion: With the global momentum to improve quality of intrapartum care, better understanding of QI package within a health facility context is important. The proposed package is based on experiences from a similar previous scale-up trial carried out in Nepal. The proposed evaluation will provide evidence on QI package and technology for implementation and scale up in similar settings.

  • 23.
    Hasson, H.
    et al.
    Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.
    Nilsen, P.
    Department of Medical and Health Sciences, Division of Community Medicine, Linköping University, Linköping, Sweden.
    Augustsson, H.
    Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.
    Ingvarsson, S.
    Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.
    Korlén, S.
    Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.
    von Thiele Schwarz, Ulrica
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare. Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.
    To do or not to do - Balancing governance and professional autonomy to abandon low-value practices: A study protocol2019In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 14, no 1, article id 70Article in journal (Refereed)
    Abstract [en]

    Background: Many interventions used in health care lack evidence of effectiveness and may be unnecessary or even cause harm, and should therefore be de-implemented. Lists of such ineffective, low-value practices are common, but these lists have little chance of leading to improvements without sufficient knowledge regarding how de-implementation can be governed and carried out. However, decisions regarding de-implementation are not only a matter of scientific evidence; the puzzle is far more complex with political, economic, and relational interests play a role. This project aims at exploring the governance of de-implementation of low-value practices from the perspectives of national and regional governments and senior management at provider organizations. Methods: Theories of complexity science and organizational alignment are used, and interviews are conducted with stakeholders involved in the governance of low-value practice de-implementation, including national and regional governments (focusing on two contrasting regions in Sweden) and senior management at provider organizations. In addition, an ongoing process for governing de-implementation in accordance with current recommendations is followed over an 18-month period to explore how governance is conducted in practice. A framework for the governance of de-implementation and policy suggestions will be developed to guide de-implementation governance. Discussion: This study contributes to knowledge about the governance of de-implementation of low-value care practices. The study provides rich empirical data from multiple system levels regarding how de-implementation of low-value practices is currently governed. The study also makes a theoretical contribution by applying the theories of complexity and organizational alignment, which may provide generalizable knowledge about the interplay between stakeholders across system levels and how and why certain factors influence the governance of de-implementation. The project employs a solution-oriented perspective by developing a framework for de-implementation of low-value practices and suggesting practical strategies to improve the governance of de-implementation. The framework and strategies can thereafter be evaluated for validity and impact in future studies. 

  • 24.
    Hasson, Henna
    et al.
    Karolinska Inst, Sweden; Stockholm Cty Council, Sweden.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Augustsson, Hanna
    Karolinska Inst, Sweden; Stockholm Cty Council, Sweden.
    Ingvarsson, Sara
    Karolinska Inst, Sweden.
    Korlen, Sara
    Karolinska Inst, Sweden.
    von Thiele Schwarz, Ulrica
    Karolinska Inst, Sweden; Malardalen Univ, Sweden.
    To do or not to do-balancing governance and professional autonomy to abandon low-value practices: a study protocol2019In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 14, article id 70Article in journal (Refereed)
    Abstract [en]

    BackgroundMany interventions used in health care lack evidence of effectiveness and may be unnecessary or even cause harm, and should therefore be de-implemented. Lists of such ineffective, low-value practices are common, but these lists have little chance of leading to improvements without sufficient knowledge regarding how de-implementation can be governed and carried out. However, decisions regarding de-implementation are not only a matter of scientific evidence; the puzzle is far more complex with political, economic, and relational interests play a role. This project aims at exploring the governance of de-implementation of low-value practices from the perspectives of national and regional governments and senior management at provider organizations.MethodsTheories of complexity science and organizational alignment are used, and interviews are conducted with stakeholders involved in the governance of low-value practice de-implementation, including national and regional governments (focusing on two contrasting regions in Sweden) and senior management at provider organizations. In addition, an ongoing process for governing de-implementation in accordance with current recommendations is followed over an 18-month period to explore how governance is conducted in practice. A framework for the governance of de-implementation and policy suggestions will be developed to guide de-implementation governance.DiscussionThis study contributes to knowledge about the governance of de-implementation of low-value care practices. The study provides rich empirical data from multiple system levels regarding how de-implementation of low-value practices is currently governed. The study also makes a theoretical contribution by applying the theories of complexity and organizational alignment, which may provide generalizable knowledge about the interplay between stakeholders across system levels and how and why certain factors influence the governance of de-implementation. The project employs a solution-oriented perspective by developing a framework for de-implementation of low-value practices and suggesting practical strategies to improve the governance of de-implementation. The framework and strategies can thereafter be evaluated for validity and impact in future studies.

  • 25.
    Hasson, Henna
    et al.
    Karolinska Inst, Sweden; Stockholm Cty Council, Sweden.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Augustsson, Hanna
    Karolinska Inst, Sweden; Stockholm Cty Council, Sweden.
    Schwarz, Ulrica von Thiele
    Karolinska Inst, Sweden; Malardalen Univ, Sweden.
    Empirical and conceptual investigation of de-implementation of low-value care from professional and health care system perspectives: a study protocol2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 67Article in journal (Refereed)
    Abstract [en]

    Background: A considerable proportion of interventions provided to patients lacks evidence of their effectiveness This implies that patients may receive ineffective, unnecessary, or even harmful care Thus, in addition to implementing evidence based practices, there is also a need to abandon interventions that are not based on best evidence, i e, low value care However, research on de implementation is limited, and there is a lack of knowledge about how effective de implementation processes should be earned out The aim of this project is to explore the phenomenon of the de implementation of low value health care practices from the perspective of professionals and the health care system. Methods: Theories of habits and developmental learning in combination with theories of organizational alignment will be used The projects work will be conducted in five steps Step 1 is a scoping review of the literature, and Step 2 has an explorative design involving interviews with health care stakeholders Step 3 has a prospective design in which workplaces and professionals are shadowed during an ongoing de implementation In Step 4, a conceptual framework for de implementation will be developed based on the previous steps In Step 5, strategies for de implementation are identified using a co design approach. Discussion: This project contributes new knowledge to implementation science consisting of empirical data, a conceptual framework, and strategy suggestions on de implementation of low value care The professionals perspectives will be highlighted, including insights into how they make decisions, handle de implementation in daily practice, and what consequences it has on their work Furthermore, the health care system perspective will be considered and new knowledge on how de implementation can be understood across health care system levels will be obtained The theories of habits and developmental learning can also offer insights into how context triggers and reinforces certain behaviors and how factors at the individual and the organizational levels interact The project employs a solution oriented perspective by developing a framework for de implementation of low value practices and suggesting practical strategies to improve de implementation processes at all levels of the health care system The framework and the strategies can thereafter be evaluated for their validity and impact in future studies.

  • 26.
    Hasson, Henna
    et al.
    Karolinska Inst, Dept Learning Informat Management & Eth, Med Management Ctr, Procome Res Grp, SE-17177 Stockholm, Sweden.;Stockholm Cty Council, Ctr Epidemiol & Community Med CES, Unit Implementat & Evaluat, SE-17129 Stockholm, Sweden..
    Nilsen, Per
    Linkoping Univ, Div Community Med, Dept Med & Hlth Sci, Linkoping, Sweden..
    Augustsson, Hanna
    Karolinska Inst, Dept Learning Informat Management & Eth, Med Management Ctr, Procome Res Grp, SE-17177 Stockholm, Sweden.;Stockholm Cty Council, Ctr Epidemiol & Community Med CES, Unit Implementat & Evaluat, SE-17129 Stockholm, Sweden..
    von Thiele Schwarz, Ulrica
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare. Karolinska Inst, Stockholm.
    Empirical and conceptual investigation of de-implementation of low-value care from professional and health care system perspectives: a study protocol2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 67Article in journal (Refereed)
    Abstract [en]

    Background: A considerable proportion of interventions provided to patients lacks evidence of their effectiveness This implies that patients may receive ineffective, unnecessary, or even harmful care Thus, in addition to implementing evidence based practices, there is also a need to abandon interventions that are not based on best evidence, i e, low value care However, research on de implementation is limited, and there is a lack of knowledge about how effective de implementation processes should be earned out The aim of this project is to explore the phenomenon of the de implementation of low value health care practices from the perspective of professionals and the health care system. Methods: Theories of habits and developmental learning in combination with theories of organizational alignment will be used The project's work will be conducted in five steps Step 1 is a scoping review of the literature, and Step 2 has an explorative design involving interviews with health care stakeholders Step 3 has a prospective design in which workplaces and professionals are shadowed during an ongoing de implementation In Step 4, a conceptual framework for de implementation will be developed based on the previous steps In Step 5, strategies for de implementation are identified using a co design approach. Discussion: This project contributes new knowledge to implementation science consisting of empirical data, a conceptual framework, and strategy suggestions on de implementation of low value care The professionals' perspectives will be highlighted, including insights into how they make decisions, handle de implementation in daily practice, and what consequences it has on their work Furthermore, the health care system perspective will be considered and new knowledge on how de implementation can be understood across health care system levels will be obtained The theories of habits and developmental learning can also offer insights into how context triggers and reinforces certain behaviors and how factors at the individual and the organizational levels interact The project employs a solution oriented perspective by developing a framework for de implementation of low value practices and suggesting practical strategies to improve de implementation processes at all levels of the health care system The framework and the strategies can thereafter be evaluated for their validity and impact in future studies.

  • 27.
    Kalkan, Almina
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Hallert, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Factors influencing rheumatologists prescription of biological treatment in rheumatoid arthritis: an interview study2014In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 9, no 153Article in journal (Refereed)
    Abstract [en]

    Background: The introduction of biological drugs involved a fundamental change in the treatment of rheumatoid arthritis (RA). The extent to which biological drugs are prescribed to RA patients in different regions in Sweden varies greatly. Previous research has indicated that differences in health care practice at the regional level might obscure differences at the individual level. The objective of this study is to explore what influences individual rheumatologists decisions when prescribing biological drugs. Method: Semi-structured interviews, utilizing closed-and open-ended questions, were conducted with senior rheumatologists, selected through a mix of random and purposive sampling. The interview questions consisted of two parts, with a "parallel mixed method" approach. In the first and main part, open-ended exploratory questions were posed about factors influencing prescription. In the second part, the rheumatologists were asked to rate predefined factors that might influence their prescription decisions. The Consolidated Framework for Implementation Research (CFIR) was used as a conceptual framework for data collection and analysis. Results: Twenty-six rheumatologists were interviewed. A constellation of various factors and their interaction influenced rheumatologists prescribing decisions, including the individual rheumatologists experiences and perceptions of the evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participation in clinical trials. The patient as an actor emerged as an important factor. Hence, factors both at organizational and individual levels influenced the prescribing of biological drugs. The factors should not be seen as individual influences but were described as influencing prescription in an interactive, nonlinear way. Conclusions: Potential factors explaining differences in prescription practice are experience and perception of the evidence on the individual level and the structure of the department and participation in clinical trials on the organizational level. The influence of patient attitudes and preferences and interpretation of scientific evidence seemed to be somewhat contradictory in the qualitative responses as compared to the quantitative rating, and this needs further exploration. An implication of the present study is that in addition to scientific knowledge, attempts to influence prescription behavior need to be multifactorial and account for interactions of factors between different actors.

  • 28.
    Keurhorst, M.
    et al.
    Radboud University of Nijmegen, Netherlands; Saxion University of Appl Science, Netherlands.
    Anderson, P.
    Newcastle University, England; Maastricht University, Netherlands.
    Heinen, M.
    Radboud University of Nijmegen, Netherlands.
    Bendtsen, Preben
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Baena, Begona
    Govt Catalonia, Spain.
    Brzozka, Krzysztof
    State Agency Prevent Alcohol Related Problems, Poland.
    Colom, Joan
    Govt Catalonia, Spain.
    Deluca, Paolo
    Kings Coll London, England.
    Drummond, Colin
    Kings Coll London, England.
    Kaner, Eileen
    Newcastle University, England.
    Kloda, Karolina
    Pomeranian Medical University, Poland.
    Mierzecki, Artur
    Pomeranian Medical University, Poland.
    Newbury-Birch, Dorothy
    University of Teesside, England.
    Okulicz-Kozaryn, Katarzyna
    State Agency Prevent Alcohol Related Problems, Poland.
    Palacio-Vieira, Jorge
    Govt Catalonia, Spain.
    Parkinson, Kathryn
    Newcastle University, England.
    Reynolds, Jillian
    Hospital Clin Barcelona, Spain.
    Ronda, Gaby
    Maastricht University, Netherlands.
    Segura, Lidia
    Govt Catalonia, Spain.
    Slodownik, Luiza
    State Agency Prevent Alcohol Related Problems, Poland.
    Spak, Fredrik
    University of Gothenburg, Sweden.
    van Steenkiste, Ben
    Maastricht University, Netherlands.
    Wallace, Paul
    UCL, England.
    Wolstenholme, Amy
    Kings Coll London, England.
    Wojnar, Marcin
    Medical University of Warsaw, Poland.
    Gual, Antoni
    Hospital Clin Barcelona, Spain.
    Laurant, M.
    Radboud University of Nijmegen, Netherlands; HAN University of Appl Science, Netherlands.
    Wensing, M.
    Radboud University of Nijmegen, Netherlands; University of Heidelberg Hospital, Germany.
    Impact of primary healthcare providers initial role security and therapeutic commitment on implementing brief interventions in managing risky alcohol consumption: a cluster randomised factorial trial2016In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 11, no 96Article in journal (Refereed)
    Abstract [en]

    Background: Brief interventions in primary healthcare are cost-effective in reducing drinking problems but poorly implemented in routine practice. Although evidence about implementing brief interventions is growing, knowledge is limited with regard to impact of initial role security and therapeutic commitment on brief intervention implementation. Methods: In a cluster randomised factorial trial, 120 primary healthcare units (PHCUs) were randomised to eight groups: care as usual, training and support, financial reimbursement, and the opportunity to refer patients to an internet-based brief intervention (e-BI); paired combinations of these three strategies, and all three strategies combined. To explore the impact of initial role security and therapeutic commitment on implementing brief interventions, we performed multilevel linear regression analyses adapted to the factorial design. Results: Data from 746 providers from 120 PHCUs were included in the analyses. Baseline role security and therapeutic commitment were found not to influence implementation of brief interventions. Furthermore, there were no significant interactions between these characteristics and allocated implementation groups. Conclusions: The extent to which providers changed their brief intervention delivery following experience of different implementation strategies was not determined by their initial attitudes towards alcohol problems. In future research, more attention is needed to unravel the causal relation between practitioners attitudes, their actual behaviour and care improvement strategies to enhance implementation science.

  • 29.
    Keurhorst, Myrna N.
    et al.
    Radboud University of Nijmegen, Netherlands.
    Anderson, Peter
    Newcastle University, United Kingdom.
    Spak, Fredrik
    University of Gothenburg, Sweden.
    Bendtsen, Preben
    Linköping University, Department of Medical and Health Sciences, Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Acute Health Care in Linköping. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Segura, Lidia
    Government of Catalonia, Barcelona, Spain.
    Colom, Joan
    Government of Catalonia, Barcelona, Spain.
    Reynolds, Jillian
    Hospital Clin Barcelona, Spain.
    Drummond, Colin
    Kings Coll London, England.
    Deluca, Paolo
    Kings Coll London, England.
    van Steenkiste, Ben
    Maastricht University, Netherlands.
    Mierzecki, Artur
    Pomeranian Medical University, Poland.
    Kloda, Karolina
    Pomeranian Medical University, Poland.
    Wallace, Paul
    UCL, England.
    Newbury-Birch, Dorothy
    Fac Med, England.
    Kaner, Eileen
    Fac Med, England.
    Gual, Toni
    Hospital Clin Barcelona, Spain.
    Laurant, Miranda G H.
    Radboud University of Nijmegen, Netherlands.
    Implementing training and support, financial reimbursement, and referral to an internet-based brief advice program to improve the early identification of hazardous and harmful alcohol consumption in primary care (ODHIN): study protocol for a cluster randomized factorial trial2013In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 8Article in journal (Refereed)
    Abstract [en]

    Background

    The European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers.

    Methods/design

    In a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals’ role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling.

    Discussion

    Effective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.

  • 30. Lippman, Sheri A.
    et al.
    Pettifor, Audrey
    Rebombo, Dumisani
    Julien, Aimee
    Wagner, Ryan G.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand Johannesburg, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa.
    Dufour, Mi-Suk Kang
    Kabudula, Chodziwadziwa Whiteson
    Neilands, Torsten B.
    Twine, Rhian
    Gottert, Ann
    Gomez-Olive, F. Xavier
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand Johannesburg, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa.
    Sanne, Ian
    Peacock, Dean
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand Johannesburg, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa.
    Evaluation of the Tsima community mobilization intervention to improve engagement in HIV testing and care in South Africa: study protocol for a cluster randomized trial2017In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 12, no 9Article in journal (Refereed)
    Abstract [en]

    Background: HIV transmission can be decreased substantially by reducing the burden of undiagnosed HIV infection and expanding early and consistent use of antiretroviral therapy (ART). Treatment as prevention (TasP) has been proposed as key to ending the HIV epidemic. To activate TasP in high prevalence countries, like South Africa, communities must be motivated to know their status, engage in care, and remain in care. Community mobilization (CM) has the potential to significantly increase uptake testing, linkage to and retention in care by addressing the primary social barriers to engagement with HIV care-including poor understanding of HIV care; fear and stigma associated with infection, clinic attendance and disclosure; lack of social support; and gender norms that deter men from accessing care. Methods/design: Using a cluster randomized trial design, we are implementing a 3-year-theory-based CM intervention and comparing gains in HIV testing, linkage, and retention in care among individuals residing in 8 intervention communities to that of individuals residing in 7 control communities. Eligible communities include 15 villages within a health and demographic surveillance site (HDSS) in rural Mpumalanga, South Africa, that were not exposed to previous CM efforts. CM activities conducted in the 8 intervention villages map onto six mobilization domains that comprise the key components for community mobilization around HIV prevention. To evaluate the intervention, we will link a clinic-based electronic clinical tracking system in all area clinics to the HDSS longitudinal census data, thus creating an open, population-based cohort with over 30,000 18-49-year-old residents. We will estimate the marginal effect of the intervention on individual outcomes using generalized estimating equations. In addition, we will evaluate CM processes by conducting baseline and endline surveys among a random sample of 1200 community residents at each time point to monitor intervention exposure and community level change using validated measures of CM. Discussion: Given the known importance of community social factors with regard to uptake of testing and HIV care, and the lack of rigorously evaluated community-level interventions effective in improving testing uptake, linkage and retention, the proposed study will yield much needed data to understand the potential of CM to improve the prevention and care cascade. Further, our work in developing a CM framework and domain measures will permit validation of a CM conceptual framework and process, which should prove valuable for community programming in Africa.

  • 31.
    MacFarlane, Anne
    et al.
    Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
    Clerkin, Pauline
    Discipline of General Practice, National University of Ireland, Galway, Galway, Ireland.
    Murray, Elizabeth
    e-Health Unit, Department of Primary Care & Population Health, University College London, Upper Floor 3, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK.
    Heaney, David J
    Centre for Rural Health, University of Aberdeen, Inverness, UK.
    Wakeling, Mary
    Centre for Rural Health, University of Aberdeen, Inverness, UK.
    Pesola, Ulla-Maija
    Umeå University, Faculty of Social Sciences, Department of Informatics.
    Waterworth, Eva L
    Umeå University, Faculty of Social Sciences, Department of Informatics.
    Larsen, Frank
    Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway.
    Mäkiniemi, Minna
    Oulu University Hospital, Northern Ostrobothnia Hospital District, Oulu, Finland.
    Winblad, Ilkka
    Oulu University, Oulu, Finland.
    The e-health implementation toolkit: qualitative evaluation across four European countries2011In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 06, no 122Article in journal (Refereed)
    Abstract [en]

    Background: Implementation researchers have attempted to overcome the research-practice gap in e-health by developing tools that summarize and synthesize research evidence of factors that impede or facilitate implementation of innovation in healthcare settings. The e-Health Implementation Toolkit (e-HIT) is an example of such a tool that was designed within the context of the United Kingdom National Health Service to promote implementation of e-health services. Its utility in international settings is unknown.

    Methods: We conducted a qualitative evaluation of the e-HIT in use across four countries--Finland, Norway, Scotland, and Sweden. Data were generated using a combination of interview approaches (n = 22) to document e-HIT users' experiences of the tool to guide decision making about the selection of e-health pilot services and to monitor their progress over time.

    Results: e-HIT users evaluated the tool positively in terms of its scope to organize and enhance their critical thinking about their implementation work and, importantly, to facilitate discussion between those involved in that work. It was easy to use in either its paper- or web-based format, and its visual elements were positively received. There were some minor criticisms of the e-HIT with some suggestions for content changes and comments about its design as a generic tool (rather than specific to sites and e-health services). However, overall, e-HIT users considered it to be a highly workable tool that they found useful, which they would use again, and which they would recommend to other e-health implementers.

    Conclusion: The use of the e-HIT is feasible and acceptable in a range of international contexts by a range of professionals for a range of different e-health systems.

  • 32.
    Maluka, Stephen
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute of Development Studies, University of Dar Es Salaam, Dar Es Salaam, Tanzania.
    Kamuzora, Peter
    Institute of Development Studies, University of Dar Es Salaam, Dar Es Salaam, Tanzania.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Byskov, Jens
    DBL-Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Thorvaldsensvej 57, DK 1871 Frederiksberg, Denmark .
    Ndawi, Benedict
    Primary Health Care Institute (PHCI), P.O.Box 235, Iringa, Tanzania .
    Olsen, Öystein E
    Haydom Lutheran Hospital, Mbulu, Manyara, Tanzania .
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Implementing accountability for reasonableness framework at district level in Tanzania: a realist evaluation2011In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 6, p. Article nr 11-Article in journal (Refereed)
    Abstract [en]

    Background: Despite the growing importance of the Accountability for Reasonableness (A4R) framework in priority setting worldwide, there is still an inadequate understanding of the processes and mechanisms underlying its influence on legitimacy and fairness, as conceived and reflected in service management processes and outcomes. As a result, the ability to draw scientifically sound lessons for the application of the framework to services and interventions is limited. This paper evaluates the experiences of implementing the A4R approach in Mbarali District, Tanzania, in order to find out how the innovation was shaped, enabled, and constrained by the interaction between contexts, mechanisms and outcomes.

    Methods: This study draws on the principles of realist evaluation - a largely qualitative approach, chiefly concerned with testing and refining programme theories by exploring the complex interactions of contexts, mechanisms, and outcomes. Mixed methods were used in data collection, including individual interviews, non-participant observation, and document reviews. A thematic framework approach was adopted for the data analysis.

    Results: The study found that while the A4R approach to priority setting was helpful in strengthening transparency, accountability, stakeholder engagement, and fairness, the efforts at integrating it into the current district health system were challenging. Participatory structures under the decentralisation framework, central government's call for partnership in district-level planning and priority setting, perceived needs of stakeholders, as well as active engagement between researchers and decision makers all facilitated the adoption and implementation of the innovation. In contrast, however, limited local autonomy, low level of public awareness, unreliable and untimely funding, inadequate accountability mechanisms, and limited local resources were the major contextual factors that hampered the full implementation.

    Conclusion: This study documents an important first step in the effort to introduce the ethical framework A4R into district planning processes. This study supports the idea that a greater involvement and accountability among local actors through the A4R process may increase the legitimacy and fairness of priority-setting decisions. Support from researchers in providing a broader and more detailed analysis of health system elements, and the socio-cultural context, could lead to better prediction of the effects of the innovation and pinpoint stakeholders' concerns, thereby illuminating areas that require special attention to promote sustainability.

  • 33.
    Marchant, Tanya
    et al.
    Department of Disease Control, London School of Hygiene and Tropical Medicine, UK.
    Schellenberg, Joanna
    Department of Disease Control, London School of Hygiene and Tropical Medicine, UK.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Manzi, Fatuma
    Ifakara Health Institute, Dar es Salaam, Tanzania.
    Waiswa, Peter
    Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
    Hanson, Claudia
    Department of Disease Control, London School of Hygiene and Tropical Medicine, UK.
    Temu, Silas
    Ifakara Health Institute, Dar es Salaam, Tanzania.
    Darious, Kajjo
    College of Health Sciences, Makerere University, Kampala, Uganda.
    Sedekia, Yovitha
    Ifakara Health Institute, Dar es Salaam, Tanzania.
    Akuze, Joseph
    College of Health Sciences, Makerere University, Kampala, Uganda.
    Rowe, Alexander K
    Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA.
    The use of continuous surveys to generate and continuously report high quality timely maternal and newborn health data at the district level in Tanzania and Uganda2014In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 9, p. 112-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    The lack of high quality timely data for evidence-informed decision making at the district level presents a challenge to improving maternal and newborn survival in low income settings. To address this problem, the EQUIP project (Expanded Quality Management using Information Power) implemented a continuous household and health facility survey for continuous feedback of data in two districts each in Tanzania and Uganda as part of a quality improvement innovation for mothers and newborns.

    METHODS:

    Within EQUIP, continuous survey data were used for quality improvement (intervention districts) and for effect evaluation (intervention and comparison districts). Over 30 months of intervention (November 2011 to April 2014), EQUIP conducted continuous cross-sectional household and health facility surveys using 24 independent probability samples of household clusters to represent each district each month, and repeat censuses of all government health facilities. Using repeat samples in this way allowed data to be aggregated at six four-monthly intervals to track progress over time for evaluation, and for continuous feedback to quality improvement teams in intervention districts.In both countries, one continuous survey team of eight people was employed to complete approximately 7,200 household and 200 facility interviews in year one. Data were collected using personal digital assistants. After every four months, routine tabulations of indicators were produced and synthesized to report cards for use by the quality improvement teams.

    RESULTS:

    The first 12 months were implemented as planned. Completion of household interviews was 96% in Tanzania and 91% in Uganda. Indicators across the continuum of care were tabulated every four months, results discussed by quality improvement teams, and report cards generated to support their work.

    CONCLUSIONS:

    The EQUIP continuous surveys were feasible to implement as a method to continuously generate and report on demand and supply side indicators for maternal and newborn health; they have potential to be expanded to include other health topics. Documenting the design and implementation of a continuous data collection and feedback mechanism for prospective description, quality improvement, and evaluation in a low-income setting potentially represents a new paradigm that places equal weight on data systems for course correction, as well as evaluation.

  • 34.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
    Making sense of implementation theories, models and frameworks2015In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 10, no 53Article in journal (Refereed)
    Abstract [en]

    Background: Implementation science has progressed towards increased use of theoretical approaches to provide better understanding and explanation of how and why implementation succeeds or fails. The aim of this article is to propose a taxonomy that distinguishes between different categories of theories, models and frameworks in implementation science, to facilitate appropriate selection and application of relevant approaches in implementation research and practice and to foster cross-disciplinary dialogue among implementation researchers. Discussion: Theoretical approaches used in implementation science have three overarching aims: describing and/or guiding the process of translating research into practice (process models); understanding and/or explaining what influences implementation outcomes (determinant frameworks, classic theories, implementation theories); and evaluating implementation (evaluation frameworks). Summary: This article proposes five categories of theoretical approaches to achieve three overarching aims. These categories are not always recognized as separate types of approaches in the literature. While there is overlap between some of the theories, models and frameworks, awareness of the differences is important to facilitate the selection of relevant approaches. Most determinant frameworks provide limited "how-to" support for carrying out implementation endeavours since the determinants usually are too generic to provide sufficient detail for guiding an implementation process. And while the relevance of addressing barriers and enablers to translating research into practice is mentioned in many process models, these models do not identify or systematically structure specific determinants associated with implementation success. Furthermore, process models recognize a temporal sequence of implementation endeavours, whereas determinant frameworks do not explicitly take a process perspective of implementation.

  • 35.
    Nilsen, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Preventive and Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, The Institute of Technology.
    Broström, Anders
    Linköping University, Department of Medical and Health Sciences, Nursing Science. Linköping University, Faculty of Health Sciences.
    Ellström, Per-Erik
    Linköping University, HELIX Vinn Excellence Centre. Linköping University, Department of Behavioural Sciences and Learning, Work and Working Life. Linköping University, Department of Behavioural Sciences and Learning, Education and Sociology. Linköping University, Faculty of Arts and Sciences.
    Creatures of habit: accounting for the role of habit in implementation research on clinical behaviour change2012In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 7, no 53Article in journal (Refereed)
    Abstract [en]

    Background: Social cognitive theories on behaviour change are increasingly being used to understand and predict healthcare professionals intentions and clinical behaviours. Although these theories offer important insights into how new behaviours are initiated, they provide an incomplete account of how changes in clinical practice occur by failing to consider the role of cue-contingent habits. This article contributes to better understanding of the role of habits in clinical practice and how improved effectiveness of behavioural strategies in implementation research might be achieved. Discussion: Habit is behaviour that has been repeated until it has become more or less automatic, enacted without purposeful thinking, largely without any sense of awareness. The process of forming habits occurs through a gradual shift in cognitive control from intentional to automatic processes. As behaviour is repeated in the same context, the control of behaviour gradually shifts from being internally guided (e. g., beliefs, attitudes, and intention) to being triggered by situational or contextual cues. Much clinical practice occurs in stable healthcare contexts and can be assumed to be habitual. Empirical findings in various fields suggest that behaviours that are repeated in constant contexts are difficult to change. Hence, interventions that focus on changing the context that maintains those habits have a greater probability of success. Some sort of contextual disturbance provides a window of opportunity in which a behaviour is more likely to be deliberately considered. Forming desired habits requires behaviour to be carried out repeatedly in the presence of the same contextual cues. Summary: Social cognitive theories provide insight into how humans analytically process information and carefully plan actions, but their utility is more limited when it comes to explaining repeated behaviours that do not require such an ongoing contemplative decisional process. However, despite a growing interest in applying behavioural theory in interventions to change clinical practice, the potential importance of habit has not been explored in implementation research.

  • 36.
    Nilsen, Per
    et al.
    Linköping University.
    Roback, Kerstin
    Linköping University.
    Broström, Anders
    Jönköping University, School of Health and Welfare, HHJ. ADULT.
    Ellström, Per-Erik
    Linköping University.
    Creatures of habit: accounting for the role of habit in implementation research on clinical behaviour change2012In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 7, article id 53Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Social cognitive theories on behaviour change are increasingly being used to understand and predict healthcare professionals' intentions and clinical behaviours. Although these theories offer important insights into how new behaviours are initiated, they provide an incomplete account of how changes in clinical practice occur by failing to consider the role of cue-contingent habits. This article contributes to better understanding of the role of habits in clinical practice and how improved effectiveness of behavioural strategies in implementation research might be achieved.

    DISCUSSION: Habit is behaviour that has been repeated until it has become more or less automatic, enacted without purposeful thinking, largely without any sense of awareness. The process of forming habits occurs through a gradual shift in cognitive control from intentional to automatic processes. As behaviour is repeated in the same context, the control of behaviour gradually shifts from being internally guided (e.g., beliefs, attitudes, and intention) to being triggered by situational or contextual cues. Much clinical practice occurs in stable healthcare contexts and can be assumed to be habitual. Empirical findings in various fields suggest that behaviours that are repeated in constant contexts are difficult to change. Hence, interventions that focus on changing the context that maintains those habits have a greater probability of success. Some sort of contextual disturbance provides a window of opportunity in which a behaviour is more likely to be deliberately considered. Forming desired habits requires behaviour to be carried out repeatedly in the presence of the same contextual cues.

    SUMMARY: Social cognitive theories provide insight into how humans analytically process information and carefully plan actions, but their utility is more limited when it comes to explaining repeated behaviours that do not require such an ongoing contemplative decisional process. However, despite a growing interest in applying behavioural theory in interventions to change clinical practice, the potential importance of habit has not been explored in implementation research.

  • 37.
    Nilsen, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Schildmeijer, Kristina
    Department of Health and Care Sciences, Linnaeus University, Kalmar, Sweden.
    Ericsson, Carin
    Region Östergötland, Heart and Medicine Center.
    Seing, Ida
    Linköping University, Department of Behavioural Sciences and Learning, Education and Sociology. Linköping University, Faculty of Arts and Sciences.
    Birken, Sarah
    Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA.
    Implementation of change in health care in Sweden: a qualitative study of professionals’ change responses2019In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 14, article id 51Article in journal (Refereed)
    Abstract [en]

    Background

    Implementation of evidence-based practices in health care implies change. Understanding health care professionals’ change responses may be critical for facilitating implementation to achieve an evidence-based practice in the rapidly changing health care environment. The aim of this study was to investigate health care professionals’ responses to organizational and workplace changes that have affected their work.

    Methods

    We conducted interviews with 30 health care professionals (physicians, registered nurses and assistant nurses) employed in the Swedish health care system. An inductive approach was applied, using a semi-structured interview guide developed by the authors. We used an analytical framework first published in 1999 to analyze the informants’ change responses in which change responses are perceived as a continuum ranging from a strong acceptance of change to strong resistance to change, describing seven forms of change responses along this continuum. Change response is conceptualized as a tridimensional attitude composed of three components: cognitive, affective and intentional/behavioral.

    Results

    Analysis of the data yielded 10 types of change responses, which could be mapped onto 5 of the 7 change response categories in the framework. Participants did not report change responses that corresponded with the two most extreme forms of responses in the framework, i.e., commitment and aggressive resistance. Most of the change responses were classified as either indifference or passive resistance to changes. Involvement in or support for changes occurred when the health care professionals initiated the changes themselves or when the changes featured their active input and when changes were seen as well founded and well communicated. We did not identify any change responses that could not be fitted into the framework.

    Conclusions

    We found the framework to be useful for a nuanced understanding of how people respond to changes. This knowledge of change responses is useful for the management of changes and for efforts to achieve more successful implementation of evidence-based practices in health care.

  • 38.
    Nilsen, Per
    et al.
    Linköping University, Sweden.
    Schildmeijer, Kristina
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Ericsson, Carin
    County Council Östergötland, Sweden.
    Seing, Ida
    Linköping University, Sweden.
    Birken, Sarah
    Univ N Carolina, USA.
    Implementation of change in health care in Sweden: a qualitative study of professionals' change responses2019In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 14, article id 51Article in journal (Refereed)
    Abstract [en]

    Background: Implementation of evidence-based practices in health care implies change. Understanding health care professionals' change responses may be critical for facilitating implementation to achieve an evidence-based practice in the rapidly changing health care environment. The aim of this study was to investigate health care professionals' responses to organizational and workplace changes that have affected their work. Methods: We conducted interviews with 30 health care professionals (physicians, registered nurses and assistant nurses) employed in the Swedish health care system. An inductive approach was applied, using a semi-structured interview guide developed by the authors. We used an analytical framework first published in 1999 to analyze the informants' change responses in which change responses are perceived as a continuum ranging from a strong acceptance of change to strong resistance to change, describing seven forms of change responses along this continuum. Change response is conceptualized as a tridimensional attitude composed of three components: cognitive, affective and intentional/behavioral. Results: Analysis of the data yielded 10 types of change responses, which could be mapped onto 5 of the 7 change response categories in the framework. Participants did not report change responses that corresponded with the two most extreme forms of responses in the framework, i.e., commitment and aggressive resistance. Most of the change responses were classified as either indifference or passive resistance to changes. Involvement in or support for changes occurred when the health care professionals initiated the changes themselves or when the changes featured their active input and when changes were seen as well founded and well communicated. We did not identify any change responses that could not be fitted into the framework. Conclusions: We found the framework to be useful for a nuanced understanding of how people respond to changes. This knowledge of change responses is useful for the management of changes and for efforts to achieve more successful implementation of evidence-based practices in health care.

  • 39.
    Nilsen, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Ståhl, Christian
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Cairney, Paul
    University of Stirling, Scotland.
    Never the twain shall meet? - a comparison of implementation science and policy implementation research2013In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 8Article in journal (Refereed)
    Abstract [en]

    Background

    Many of society’s health problems require research-based knowledge acted on by healthcare practitioners together with implementation of political measures from governmental agencies. However, there has been limited knowledge exchange between implementation science and policy implementation research, which has been conducted since the early 1970s. Based on a narrative review of selective literature on implementation science and policy implementation research, the aim of this paper is to describe the characteristics of policy implementation research, analyze key similarities and differences between this field and implementation science, and discuss how knowledge assembled in policy implementation research could inform implementation science.

    Discussion

    Following a brief overview of policy implementation research, several aspects of the two fields were described and compared: the purpose and origins of the research; the characteristics of the research; the development and use of theory; determinants of change (independent variables); and the impact of implementation (dependent variables). The comparative analysis showed that there are many similarities between the two fields, yet there are also profound differences. Still, important learning may be derived from several aspects of policy implementation research, including issues related to the influence of the context of implementation and the values and norms of the implementers (the healthcare practitioners) on implementation processes. Relevant research on various associated policy topics, including The Advocacy Coalition Framework, Governance Theory, and Institutional Theory, may also contribute to improved understanding of the difficulties of implementing evidence in healthcare. Implementation science is at a relatively early stage of development, and advancement of the field would benefit from accounting for knowledge beyond the parameters of the immediate implementation science literature.

    Summary

    There are many common issues in policy implementation research and implementation science. Research in both fields deals with the challenges of translating intentions into desired changes. Important learning may be derived from several aspects of policy implementation research.

  • 40.
    Nilsen, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Wallerstedt, Birgitta
    Linnaeus University, Sweden.
    Behm, Lina
    Lund University, Sweden.
    Ahlstroem, Gerd
    Lund University, Sweden.
    Towards evidence-based palliative care in nursing homes in Sweden: a qualitative study informed by the organizational readiness to change theory2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 1Article in journal (Refereed)
    Abstract [en]

    Background: Sweden has a policy of supporting older people to live a normal life at home for as long as possible. Therefore, it is often the oldest, most frail people who move into nursing homes. Nursing home staff are expected to meet the existential needs of the residents, yet conversations about death and dying tend to cause emotional strain. This study explores organizational readiness to implement palliative care based on evidence-based guidelines in nursing homes in Sweden. The aim was to identify barriers and facilitators to implementing evidence-based palliative care in nursing homes. Methods: Interviews were carried out with 20 managers from 20 nursing homes in two municipalities who had participated along with staff members in seminars aimed at conveying knowledge and skills of relevance for providing evidence-based palliative care. Two managers responsible for all elderly care in each municipality were also interviewed. The questions were informed by the theory of Organizational Readiness for Change (ORC). ORC was also used as a framework to analyze the data by means of categorizing barriers and facilitators for implementing evidence-based palliative care. Results: Analysis of the data yielded ten factors (i.e., sub-categories) acting as facilitators and/or barriers. Four factors constituted barriers: the staffs beliefs in their capabilities to face dying residents, their attitudes to changes at work as well as the resources and time required. Five factors functioned as either facilitators or barriers because there was considerable variation with regard to the staffs competence and confidence, motivation, and attitudes to work in general, as well as the managers plans and decisional latitude concerning efforts to develop evidence-based palliative care. Leadership was a facilitator to implementing evidence-based palliative care. Conclusions: There is a limited organizational readiness to develop evidence-based palliative care as a result of variation in the nursing home staffs change efficacy and change commitment as well as restrictions in many contextual conditions. There are considerable individual-and organizational-level challenges to achieving evidence-based palliative care in this setting. The educational intervention represents one of many steps towards developing a culture conducive to evidence-based nursing home palliative care.

  • 41.
    Nilsen, Per
    et al.
    Linköping University.
    Wallerstedt, Birgitta
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Behm, Lina
    Lund University.
    Ahlstroem, Gerd
    Lund University.
    Towards evidence-based palliative care in nursing homes in Sweden: a qualitative study informed by the organizational readiness to change theory2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 1Article in journal (Refereed)
    Abstract [en]

    Background: Sweden has a policy of supporting older people to live a normal life at home for as long as possible. Therefore, it is often the oldest, most frail people who move into nursing homes. Nursing home staff are expected to meet the existential needs of the residents, yet conversations about death and dying tend to cause emotional strain. This study explores organizational readiness to implement palliative care based on evidence-based guidelines in nursing homes in Sweden. The aim was to identify barriers and facilitators to implementing evidence-based palliative care in nursing homes. Methods: Interviews were carried out with 20 managers from 20 nursing homes in two municipalities who had participated along with staff members in seminars aimed at conveying knowledge and skills of relevance for providing evidence-based palliative care. Two managers responsible for all elderly care in each municipality were also interviewed. The questions were informed by the theory of Organizational Readiness for Change (ORC). ORC was also used as a framework to analyze the data by means of categorizing barriers and facilitators for implementing evidence-based palliative care. Results: Analysis of the data yielded ten factors (i.e., sub-categories) acting as facilitators and/or barriers. Four factors constituted barriers: the staff's beliefs in their capabilities to face dying residents, their attitudes to changes at work as well as the resources and time required. Five factors functioned as either facilitators or barriers because there was considerable variation with regard to the staff's competence and confidence, motivation, and attitudes to work in general, as well as the managers' plans and decisional latitude concerning efforts to develop evidence-based palliative care. Leadership was a facilitator to implementing evidence-based palliative care. Conclusions: There is a limited organizational readiness to develop evidence-based palliative care as a result of variation in the nursing home staff's change efficacy and change commitment as well as restrictions in many contextual conditions. There are considerable individual-and organizational-level challenges to achieving evidence-based palliative care in this setting. The educational intervention represents one of many steps towards developing a culture conducive to evidence-based nursing home palliative care.

  • 42.
    Nilsen, Per
    et al.
    Linköping University.
    Wallerstedt, Birgitta
    Linnaeus University.
    Behm, Lina
    Lund University.
    Ahlström, Gerd
    Lund University.
    Towards evidence-based palliative care in nursing homes in Sweden: a qualitative study informed by the organizational readiness to change theory2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, no 1, article id 1Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Sweden has a policy of supporting older people to live a normal life at home for as long as possible. Therefore, it is often the oldest, most frail people who move into nursing homes. Nursing home staff are expected to meet the existential needs of the residents, yet conversations about death and dying tend to cause emotional strain. This study explores organizational readiness to implement palliative care based on evidence-based guidelines in nursing homes in Sweden. The aim was to identify barriers and facilitators to implementing evidence-based palliative care in nursing homes.

    METHODS: Interviews were carried out with 20 managers from 20 nursing homes in two municipalities who had participated along with staff members in seminars aimed at conveying knowledge and skills of relevance for providing evidence-based palliative care. Two managers responsible for all elderly care in each municipality were also interviewed. The questions were informed by the theory of Organizational Readiness for Change (ORC). ORC was also used as a framework to analyze the data by means of categorizing barriers and facilitators for implementing evidence-based palliative care.

    RESULTS: Analysis of the data yielded ten factors (i.e., sub-categories) acting as facilitators and/or barriers. Four factors constituted barriers: the staff's beliefs in their capabilities to face dying residents, their attitudes to changes at work as well as the resources and time required. Five factors functioned as either facilitators or barriers because there was considerable variation with regard to the staff's competence and confidence, motivation, and attitudes to work in general, as well as the managers' plans and decisional latitude concerning efforts to develop evidence-based palliative care. Leadership was a facilitator to implementing evidence-based palliative care.

    CONCLUSIONS: There is a limited organizational readiness to develop evidence-based palliative care as a result of variation in the nursing home staff's change efficacy and change commitment as well as restrictions in many contextual conditions. There are considerable individual- and organizational-level challenges to achieving evidence-based palliative care in this setting. The educational intervention represents one of many steps towards developing a culture conducive to evidence-based nursing home palliative care.

  • 43.
    Pallangyo, Eunice N.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. School of Nursing and Midwifery, Aga Khan University, Salama House, 344 Urambo Street, P.O.BOX 38129, Dar es Salaam, Tanzania.
    Mbekenga, Columba
    School of Nursing and Midwifery, Aga Khan University, Salama House, 344 Urambo Street, P.O.BOX 38129, Dar es Salaam, Tanzania.
    Olsson, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Eriksson, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Implementation of a facilitation intervention to improve postpartum care in a low resource suburb in Dar es Salaam, Tanzania2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 102Article in journal (Refereed)
    Abstract [en]

    Background

    Implementation of evidence into practice is inadequate in many low-income countries, contributing to the low-quality care of mothers and newborns. This study explored strategies used in a facilitation intervention to improve postpartum care (IPPC) in a low-resource suburb in Dar es Salaam, Tanzania. The intervention was conducted during 1 year in government-owned health institutions providing reproductive and child health services. The institutions were divided into six clusters based on geographic proximity, and the healthcare providers of postpartum care (PPC) (n = 100) in these institutions formed IPPC teams. Each team was supported by a locally recruited facilitator who was trained in PPC, group dynamics, and quality improvement. The IPPC teams reflected on their practices, identified problems and solutions for improving PPC, enacted change, and monitored the adopted actions.

    Methods

    A qualitative design was employed using data from focus group discussions with healthcare providers (n = 8) and facilitators (n = 2), and intervention documentation. The discussions were conducted in Kiswahili, lasted for 45–90 min, were audio-recorded, transcribed verbatim, and translated into English. Thematic analysis guided the analysis.

    Results

    Four main strategies were identified in the data: (1) Increasing awareness and knowledge of PPC by HCPs and mothers was an overarching strategy applied in training, meetings, and clinical practice; (2) The mobilization of professional and material resources was achieved through unleashing of the IPPC teams’ own potential to conduct PPC and act as change agents; (3) Improving documentation and communication; and (4) Promoting an empowering and collaborative working style were other strategies applied to improve daily care routines. The facilitators encouraged teamwork and networking among IPPC teams within and between institutions.

    Conclusion

    This facilitation intervention is a promising approach for implementing evidence and improving quality of PPC in a low-resource setting. Context-specific actions taken by the facilitators and healthcare providers are likely integral to the successfulness of implementing evidence into practice. The results contribute to increasing the understanding of facilitation as an intervention and can be useful for researchers, HCPs, and policymakers when improving quality of postpartum care, particularly in low-income settings.

  • 44.
    Richter, Anne
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Work and organizational psychology. Karolinska Institutet, Sweden; Stockholm County Council, Sweden.
    von Thiele Schwarz, Ulrica
    Lornudd, Caroline
    Lundmark, Robert
    Mosson, Rebecca
    Hasson, Henna
    iLead—a transformational leadership intervention to train healthcare managers’ implementation leadership2016In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 11, article id 108Article in journal (Refereed)
    Abstract [en]

    Background: Leadership is a key feature in implementation efforts, which is highlighted in most implementation frameworks. However, in studying leadership and implementation, only few studies rely on established leadership theory, which makes it difficult to draw conclusions regarding what kinds of leadership managers should perform and under what circumstances. In industrial and organizational psychology, transformational leadership and contingent reward have been identified as effective leadership styles for facilitating change processes, and these styles map well onto the behaviors identified in implementation research. However, it has been questioned whether these general leadership styles are sufficient to foster specific results; it has therefore been suggested that the leadership should be specific to the domain of interest, e.g., implementation. To this end, an intervention specifically involving leadership, which we call implementation leadership, is developed and tested in this project. The aim of the intervention is to increase healthcare managers’ generic implementation leadership skills, which they can use for any implementation efforts in the future.

    Methods/design: The intervention is conducted in healthcare in Stockholm County, Sweden, where first- and second-line managers were invited to participate. Two intervention groups are included, including 52 managers. Intervention group 1 consists of individual managers, and group 2 of managers from one division. A control group of 39 managers is additionally included. The intervention consists of five half-day workshops aiming at increasing the managers’ implementation leadership, which is the primary outcome of this intervention. The intervention will be evaluated through a mixed-methods approach. A pre- and post-design applying questionnaires at three time points (pre-, directly after the intervention, and 6 months post-intervention) will be used, in addition to process evaluation questionnaires related to each workshop. In addition, interviews will be conducted over time to evaluate the intervention.

    Discussion: The proposed intervention represents a novel contribution to the implementation literature, being the first to focus on strengthening healthcare managers’ generic skills in implementation leadership.

  • 45. Richter, Anne
    et al.
    von Thiele Schwarz, Ulrica
    Lornudd, Caroline
    Lundmark, Robert
    Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77 Stockholm, Sweden.
    Mosson, Rebecca
    Hasson, Henna
    iLead-a transformational leadership intervention to train healthcare managers' implementation leadership2016In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 11, article id 108Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Leadership is a key feature in implementation efforts, which is highlighted in most implementation frameworks. However, in studying leadership and implementation, only few studies rely on established leadership theory, which makes it difficult to draw conclusions regarding what kinds of leadership managers should perform and under what circumstances. In industrial and organizational psychology, transformational leadership and contingent reward have been identified as effective leadership styles for facilitating change processes, and these styles map well onto the behaviors identified in implementation research. However, it has been questioned whether these general leadership styles are sufficient to foster specific results; it has therefore been suggested that the leadership should be specific to the domain of interest, e.g., implementation. To this end, an intervention specifically involving leadership, which we call implementation leadership, is developed and tested in this project. The aim of the intervention is to increase healthcare managers' generic implementation leadership skills, which they can use for any implementation efforts in the future.

    METHODS/DESIGN: The intervention is conducted in healthcare in Stockholm County, Sweden, where first- and second-line managers were invited to participate. Two intervention groups are included, including 52 managers. Intervention group 1 consists of individual managers, and group 2 of managers from one division. A control group of 39 managers is additionally included. The intervention consists of five half-day workshops aiming at increasing the managers' implementation leadership, which is the primary outcome of this intervention. The intervention will be evaluated through a mixed-methods approach. A pre- and post-design applying questionnaires at three time points (pre-, directly after the intervention, and 6 months post-intervention) will be used, in addition to process evaluation questionnaires related to each workshop. In addition, interviews will be conducted over time to evaluate the intervention.

    DISCUSSION: The proposed intervention represents a novel contribution to the implementation literature, being the first to focus on strengthening healthcare managers' generic skills in implementation leadership.

  • 46.
    Rycroft-Malone, Jo
    et al.
    Bangor Univ, Wales.
    Seers, Kate
    Univ Warwick, England.
    Eldh, Ann Catrine
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences.
    Cox, Karen
    Fontys Univ Appl Sci, Netherlands.
    Crichton, Nicola
    London South Bank Univ, England.
    Harvey, Gill
    Univ Adelaide, Australia.
    Hawkes, Claire
    Univ Warwick, England.
    Kitson, Alison
    Flinders Univ S Australia, Australia.
    McCormack, Brendan
    Queen Margaret Univ Edinburgh, Scotland.
    McMullan, Christel
    Univ Birmingham, England.
    Mockford, Carole
    Univ Warwick, England.
    Niessen, Theo
    Fontys Univ Appl Sci, Netherlands.
    Slater, Paul
    Ulster Univ, North Ireland.
    Titchen, Angie
    Ulster Univ, North Ireland.
    van der Zijpp, Teatske
    Fontys Univ Appl Sci, Netherlands.
    Wallin, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Div Nursing, Dept Neurobiol Care Sci and Soc, Stockholm, Sweden; Dalarna Univ, Sweden; Univ Gothenburg, Sweden.
    A realist process evaluation within the Facilitating Implementation of Research Evidence (FIRE) cluster randomised controlled international trial: an exemplar2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 138Article in journal (Refereed)
    Abstract [en]

    BackgroundFacilitation is a promising implementation intervention, which requires theory-informed evaluation. This paper presents an exemplar of a multi-country realist process evaluation that was embedded in the first international randomised controlled trial evaluating two types of facilitation for implementing urinary continence care recommendations. We aimed to uncover what worked (and did not work), for whom, how, why and in what circumstances during the process of implementing the facilitation interventions in practice.MethodsThis realist process evaluation included theory formulation, theory testing and refining. Data were collected in 24 care home sites across four European countries. Data were collected over four time points using multiple qualitative methods: observation (372h), interviews with staff (n=357), residents (n=152), next of kin (n=109) and other stakeholders (n=128), supplemented by facilitator activity logs. A combined inductive and deductive data analysis process focused on realist theory refinement and testing.ResultsThe content and approach of the two facilitation programmes prompted variable opportunities to align and realign support with the needs and expectations of facilitators and homes. This influenced their level of confidence in fulfilling the facilitator role and ability to deliver the intervention as planned. The success of intervention implementation was largely dependent on whether sites prioritised their involvement in both the study and the facilitation programme. In contexts where the study was prioritised (including release of resources) and where managers and staff support was sustained, this prompted collective engagement (as an attitude and action). Internal facilitators (IF) personal characteristics and abilities, including personal and formal authority, in combination with a supportive environment prompted by managers triggered the potential for learning over time. Learning over time resulted in a sense of confidence and personal growth, and enactment of the facilitation role, which resulted in practice changes.ConclusionThe scale and multi-country nature of this study provided a novel context to conduct one of the few trial embedded realist-informed process evaluations. In addition to providing an explanatory account of implementation processes, a conceptual platform for future facilitation research is presented. Finally, a realist-informed process evaluation framework is outlined, which could inform future research of this nature.Trial registrationCurrent controlled trials ISRCTN11598502.

  • 47. Rycroft-Malone, Jo
    et al.
    Seers, Kate
    Eldh, Ann Catrine
    Cox, Karen
    Crichton, Nicola
    Harvey, Gill
    Hawkes, Claire
    Kitson, Alison
    McCormack, Brendan
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet; Göteborgs universitet.
    A realist process evaluation within the Facilitating Implementation of Research Evidence (FIRE) cluster randomised controlled international trial: an exemplar2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, no 1, article id 138Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Facilitation is a promising implementation intervention, which requires theory-informed evaluation. This paper presents an exemplar of a multi-country realist process evaluation that was embedded in the first international randomised controlled trial evaluating two types of facilitation for implementing urinary continence care recommendations. We aimed to uncover what worked (and did not work), for whom, how, why and in what circumstances during the process of implementing the facilitation interventions in practice.

    METHODS: This realist process evaluation included theory formulation, theory testing and refining. Data were collected in 24 care home sites across four European countries. Data were collected over four time points using multiple qualitative methods: observation (372 h), interviews with staff (n = 357), residents (n = 152), next of kin (n = 109) and other stakeholders (n = 128), supplemented by facilitator activity logs. A combined inductive and deductive data analysis process focused on realist theory refinement and testing.

    RESULTS: The content and approach of the two facilitation programmes prompted variable opportunities to align and realign support with the needs and expectations of facilitators and homes. This influenced their level of confidence in fulfilling the facilitator role and ability to deliver the intervention as planned. The success of intervention implementation was largely dependent on whether sites prioritised their involvement in both the study and the facilitation programme. In contexts where the study was prioritised (including release of resources) and where managers and staff support was sustained, this prompted collective engagement (as an attitude and action). Internal facilitators' (IF) personal characteristics and abilities, including personal and formal authority, in combination with a supportive environment prompted by managers triggered the potential for learning over time. Learning over time resulted in a sense of confidence and personal growth, and enactment of the facilitation role, which resulted in practice changes.

    CONCLUSION: The scale and multi-country nature of this study provided a novel context to conduct one of the few trial embedded realist-informed process evaluations. In addition to providing an explanatory account of implementation processes, a conceptual platform for future facilitation research is presented. Finally, a realist-informed process evaluation framework is outlined, which could inform future research of this nature.

    TRIAL REGISTRATION: Current controlled trials ISRCTN11598502 .

  • 48.
    Sandström, Boel
    et al.
    Blekinge Institute of Technology, Faculty of Health Sciences, Department of Health.
    Willman, Ania
    Blekinge Institute of Technology, Faculty of Health Sciences, Department of Health.
    Svensson, Bengt
    Borglin, Gunilla
    Blekinge Institute of Technology, Faculty of Health Sciences, Department of Health.
    Perceptions of national guidelines and their (non) implementation in mental healthcare: a deductive and inductive content analysis2015In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 10, no 1, article id 43Article in journal (Refereed)
    Abstract [en]

    Background: National guidelines are being produced at an increasing rate, and politicians and managers are expected to promote these guidelines and their implementation in clinical work. However, research seldom deals with how decision-makers can perceive these guidelines or their challenges in a cultural context. Therefore, the aim of this study was twofold: to investigate how well Promoting Action on Research Implementation in Health Services (PARIHS) reflected the empirical reality of mental healthcare and to gain an extended understanding of the perceptions of decision-makers operating within this context, in regard to the implementation of evidence-based guidelines. Methods: The study took place in the southeast of Sweden and employed a qualitative design. The data were collected through 23 interviews with politicians and managers working either in the county council or in the municipalities. The transcribed text was analysed iteratively and in two distinct phases, first deductively and second inductively by means of qualitative content analysis. Results: Our deductive analysis showed that the text strongly reflected two out of three categorisation matrices, i.e. evidence and context representing the PARIHS framework. However, the key element of facilitation was poorly mirrored in the text. Results from the inductive analysis can be seen in light of the main category sitting on the fence; thus, the informants' perceptions reflected ambivalence and contradiction. This was illustrated by conflicting views and differences in culture and ideology, a feeling of security in tradition, a certain amount of resistance to change and a lack of role clarity and clear directions. Together, our two analyses provide a rich description of an organisational culture that is highly unlikely to facilitate the implementation of the national guidelines, together with a distrust of the source behind such guidelines, which stands in stark contrast to the high confidence in the knowledge of experienced people in authority within the organisational context. Conclusions: Our findings have highlighted that, regardless of by whom guidelines are released, they are not likely to be utilised or implemented if those who are responsible for implementing them do not trust the source. This aspect (i.e. contextual trust) is not covered by PARIHS.

  • 49. Seers, K.
    et al.
    Rycroft-Malone, J.
    Cox, K.
    Crichton, N.
    Edwards, R. T.
    Eldh, Ann Catrine
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Estabrooks, C. A.
    Harvey, G.
    Hawkes, C.
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet; Göteborgs universitet.
    Facilitating Implementation of Research Evidence (FIRE): An international cluster randomised controlled trial to evaluate two models of facilitation informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, no 1, article id 137Article in journal (Refereed)
    Abstract [en]

    Background

    Health care practice needs to be underpinned by high quality research evidence, so that the best possible care can be delivered. However, evidence from research is not always utilised in practice. This study used the Promoting Action on Research Implementation in Health Services (PARIHS) framework as its theoretical underpinning to test whether two different approaches to facilitating implementation could affect the use of research evidence in practice.

    Methods

    A pragmatic clustered randomised controlled trial with embedded process and economic evaluation was used. The study took place in four European countries across 24 long-term nursing care sites, for people aged 60 years or more with documented urinary incontinence. In each country, sites were randomly allocated to standard dissemination, or one of two different types of facilitation. The primary outcome was the documented percentage compliance with the continence recommendations, assessed at baseline, then at 6, 12, 18, and 24 months after the intervention.

    Data were analysed using STATA15, multi-level mixed-effects linear regression models were fitted to scores for compliance with the continence recommendations, adjusting for clustering.

    Results

    Quantitative data were obtained from reviews of 2313 records. There were no significant differences in the primary outcome (documented compliance with continence recommendations) between study arms and all study arms improved over time.

    Conclusions

    This was the first cross European randomised controlled trial with embedded process evaluation that sought to test different methods of facilitation. There were no statistically significant differences in compliance with continence recommendations between the groups. It was not possible to identify whether different types and “doses” of facilitation were influential within very diverse contextual conditions. The process evaluation (Rycroft-Malone et al., Implementation Science. doi: 10.1186/s13012-018-0811-0) revealed the models of facilitation used were limited in their ability to overcome the influence of contextual factors.

    Trial registration

    Current Controlled Trials ISRCTN11598502. Date 4/2/10.

    The research leading to these results has received funding from the European Union’s Seventh Framework Programme (FP7/2007–2013) under grant agreement no. 223646.

  • 50.
    Seers, Kate
    et al.
    Royal College of Nursing Research Institute, School of Health and Social Studies, University of Warwick, Coventry, UK.
    Cox, Karen
    Fontys University of Applied Sciences School of Nursing, Eindhoven, the Netherlands.
    Crichton, Nicola J
    Faculty of Health and Social Care, London South Bank University, UK.
    Edwards, Rhiannon Tudor
    Bangor University, Centre for Economics and Policy in Health/Canolfan Economeg a Pholisi Iechyd, IMSCaR, College of Health and Behavioural Sciences, Bangor University, UK.
    Eldh, Ann Catrine
    Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet and Clinical Research Utilization (CRU), Karolinska University Hospital, Eugeniahemmet, Stockholm, Sweden.
    Estabrooks, Carole A
    Faculty of Nursing, University of Alberta, Edmonton, Canada.
    Harvey, Gill
    Health Management Group, Manchester Business School, University of Manchester, UK.
    Hawkes, Claire
    Bangor University, Centre for Health Related Research, School of Healthcare Sciences, College of Health and Behavioural Sciences, Fron Heulog, Bangor University, UK.
    Kitson, Alison
    School of Nursing, University of Adelaide, Australia.
    Linck, Pat
    Bangor University, Centre for Economics and Policy in Health/Canolfan Economeg a Pholisi Iechyd, IMSCaR, College of Health and Behavioural Sciences, Bangor University, UK.
    McCarthy, Geraldine
    University College Cork, College of Medicine & Health, Cork, Republic of Ireland.
    McCormack, Brendan
    Institute of Nursing Research/School of Nursing, University of Ulster, Newtownabbey, Northern Ireland.
    Mockford, Carole
    Royal College of Nursing Research Institute, School of Health and Social Studies, University of Warwick, Coventry, UK.
    Rycroft-Malone, Jo
    Bangor University, Centre for Health Related Research, School of Healthcare Sciences, College of Health and Behavioural Sciences, Fron Heulog, Bangor University, Bangor, Gwynedd, UK.
    Titchen, Angie
    Fontys University of Applied Sciences School of Nursing, Eindhoven, the Netherlands.
    Wallin, Lars
    Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet and Clinical Research Utilization (CRU), Karolinska University Hospital, Eugeniahemmet, Stockholm, Sweden.
    FIRE (Facilitating Implementation of Research Evidence): a study protocol.2012In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 7, article id 25Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Research evidence underpins best practice, but is not always used in healthcare. The Promoting Action on Research Implementation in Health Services (PARIHS) framework suggests that the nature of evidence, the context in which it is used, and whether those trying to use evidence are helped (or facilitated) affect the use of evidence. Urinary incontinence has a major effect on quality of life of older people, has a high prevalence, and is a key priority within European health and social care policy. Improving continence care has the potential to improve the quality of life for older people and reduce the costs associated with providing incontinence aids.

    OBJECTIVES: This study aims to advance understanding about the contribution facilitation can make to implementing research findings into practice via: extending current knowledge of facilitation as a process for translating research evidence into practice; evaluating the feasibility, effectiveness, and cost-effectiveness of two different models of facilitation in promoting the uptake of research evidence on continence management; assessing the impact of contextual factors on the processes and outcomes of implementation; and implementing a pro-active knowledge transfer and dissemination strategy to diffuse study findings to a wide policy and practice community.

    SETTING AND SAMPLE: Four European countries, each with six long-term nursing care sites (total 24 sites) for people aged 60 years and over with documented urinary incontinence

    METHODS AND DESIGN: Pragmatic randomised controlled trial with three arms (standard dissemination and two different programmes of facilitation), with embedded process and economic evaluation. The primary outcome is compliance with the continence recommendations. Secondary outcomes include proportion of residents with incontinence, incidence of incontinence-related dermatitis, urinary tract infections, and quality of life. Outcomes are assessed at baseline, then at 6, 12, 18, and 24 months after the start of the facilitation interventions. Detailed contextual and process data are collected throughout, using interviews with staff, residents and next of kin, observations, assessment of context using the Alberta Context Tool, and documentary evidence. A realistic evaluation framework is used to develop explanatory theory about what works for whom in what circumstances.

    TRIAL REGISTRATION: Current Controlled Trials ISRCTN11598502.

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