Implementation research and practice最新文献

Purpose: The objective of this study was to determine how to optimize implementation of tobacco cessation treatment interventions in cancer care by (1) investigating the feasibility and acceptability of a multi-level approach to tobacco cessation treatment intervention, (2) identifying barriers and facilitators to implementation, and (3) eliciting additional strategies to improve implementation of the intervention.

Methods: We conducted qualitative interviews with oncologists (n = 15) from one large academic health center in the Southeastern United States. We asked about their knowledge, attitudes, and current practices regarding tobacco use screening and treatment. We also asked about two proposed strategies to support implementation of tobacco cessation treatment: (1) developing a registry of tobacco users in collaboration with the state-run tobacco cessation program, and (2) providing on-site tobacco cessation counseling from trained professionals.

Results: Oncologists saw addressing tobacco use as valuable; however, they felt restricted from consistently addressing tobacco use by multi-level barriers such as workload, electronic health record (EHR) design, patient anxiety, and low self-efficacy for treating tobacco dependence. Oncologists responded positively to on-site treatment and felt this strategy would increase treatment accessibility and enhance engagement. Reaction to developing a registry of tobacco users was mixed, with concerns regarding lack of oncologist involvement and patient privacy expressed. Other suggested strategies for supporting implementation of tobacco cessation treatment included reducing referral complexity, establishing financial or quality incentives for oncologists, and leveraging existing EHR tools to facilitate integration of cessation interventions into clinic workflows.

Conclusion: We identified several challenges to implementing tobacco use treatment in cancer care; however, we considered strategies to overcome these barriers that were viewed as feasible and acceptable. Our work highlights the importance of engaging stakeholders in implementation efforts. Future work should explore the impact of the implementation strategies identified in this study.

Background: Champions are widely recognized as playing a key role in the successful implementation of evidence-based interventions within the health care sector; however, little is known about which characteristics and skills enable them to play that role. Furthermore, previous studies have measured only individual champions' responses to personal attributes without incorporating input from other observers. A mixed-methods study was conducted to identify, analyze, and group the behaviors and characteristics of champions who have successfully promoted the adoption of new initiatives within the health care delivery system, taking into consideration self and peer perspectives.

Methods: Using a mixed-methods, cross-sectional triangulation design with a convergence model, quantitative data were collected and analyzed from health care champions (n = 30) and their colleagues (n = 58) from 11 countries using a survey. Every champion and a subset of colleagues (n = 14) also participated in in-depth interviews. Descriptive statistics were used to explore the relationship between champion and colleague responses to survey items; chi-squared tests and Kruskal-Wallis tests were used to compare the differences. Thematic content analysis of qualitative data was used to explore champion-like behaviors and features. Characteristics of champions were categorized using the Transformational Leadership Theory framework.

Results: Champions exhibited characteristics that facilitated trust and encouraged motivation among their colleagues to adopt innovations, such as being intrinsically motivated, persistent, enthusiastic, and highly effective communicators. Champions were described by their colleagues as empathetic, curious, physically present, approachable, and often soliciting feedback from others. Although there was a high degree of agreement between champion and colleague survey responses, champions were more likely to underrate their skills and abilities to instigate change compared to their colleagues.

Conclusion: Both champions and colleagues described key champion-like characteristics, but champions often downplayed the characteristics and behaviors that make champions uniquely effective at facilitating the adoption of evidence-based interventions.

Plan language abstract: Health care champions are people who promote the adoption of new initiatives to improve the quality of patient care among their colleagues within health care settings. Champions are often viewed by organizational leaders and researchers as critical for the successful implementation of new ideas; however, little is known about what specific skills or characteristics make them effective at promoting the adoption of new ideas among their colleagues. Most studies on champions' behaviors have only included the perspectives of champions, and not perspectives from others within the organiza

Background: Inner context organizational factors proximally shape therapist experiences with evidence-based practice (EBP) implementation and may influence therapist self-efficacy, which has been linked to sustained use of EBPs in community mental health settings. Research has primarily focused on constructs such as implementation leadership and climate. However, the effects of such factors may depend upon other inner context dimensions, such as psychological safety. Psychologically safe environments are conducive to taking risks, speaking up about problems, and requesting feedback and may promote therapist self-efficacy during implementation. This study examines whether organizational sustainment leadership and sustainment climate relate to therapist EBP self-efficacy only under conditions of psychological safety.

Methods: Data were collected from 410 clinicians in 85 programs during the sustainment phase of a system-driven implementation of multiple EBPs in children's mental health services. Therapists reported on their organization's sustainment leadership, sustainment climate, psychological safety, and their own self-efficacy in delivering specific EBPs. Multilevel regression analyses were conducted to account for nested data structure.

Results: Among program-level variables, sustainment leadership and psychological safety both significantly predicted therapist self-efficacy. However, there were no significant interactions between program-level sustainment climate and psychological safety. Exploratory post-hoc analyses revealed a significant interaction between program-level sustainment leadership and therapist-level perceptions of psychological safety such that that the conditional effect of psychological safety on EBP self-efficacy was significant at high levels of sustainment leadership, but not at low or average levels.

Conclusion: We noted independent links between sustainment leadership, organizational psychological safety and therapists feelings of confidence and mastery with EBPs. Therapists' individual perceptions of psychological safety were linked to self-efficacy only in programs with high sustainment leadership. Thus, sustainment leadership and psychological safety may both represent implementation intervention targets, but it may not be critical to assess for perceptions of psychological safety before deploying organizational leadership strategies.Plain language abstract Therapist self-efficacy is a therapist's belief that they are capable, knowledgeable, and skilled enough to deliver evidence-based practices (EBPs), and is thought to promote improved clinical and implementation outcomes, such as therapists' sustained use of EBPs. Conditions within community mental health organizations may influence therapists' sense of EBP self-efficacy. Leaders' support and expectations for EBP implementation, and collective staff perceptions about

Background: Health systems increasingly need to implement complex practice changes such as the routine capture of patient-reported outcome (PRO) measures. Yet, health systems have met challenges when trying to bring practice change to scale across systems at large. While implementation science can guide the evaluation of implementation determinants, teams first need tools to systematically understand and compare workflow activities across practice sites. Structured analysis and design technique (SADT), a system engineering method of workflow modeling, may offer an opportunity to enhance the scalability of implementation evaluation for complex practice change like PROs.

Method: We utilized SADT to identify the core workflow activities needed to implement PROs across diverse settings and goals for use, establishing a generalizable PRO workflow diagram. We then used the PRO workflow diagram to guide implementation monitoring and evaluation for a 1-year pilot implementation of the electronic Patient Health Questionnaire-9 (ePHQ). The pilot occurred across multiple clinical settings and for two clinical use cases: depression screening and depression management.

Results: SADT identified five activities central to the use of PROs in clinical care: deploying PRO measures, collecting PRO data, tracking PRO completion, reviewing PRO results, and documenting PRO data for future use. During the 1-year pilot, 8,596 patients received the ePHQ for depression screening via the patient portal, of which 1,719 (21%) submitted the ePHQ; 367 patients received the ePHQ for depression management, of which 174 (47%) submitted the ePHQ. We present three case examples of how the SADT PRO workflow diagram augmented implementation monitoring, tailoring, and evaluation activities.

Conclusions: Use of a generalizable PRO workflow diagram aided the ability to systematically assess barriers and facilitators to fidelity and identify needed adaptations. The use of SADT offers an opportunity to align systems science and implementation science approaches, augmenting the capacity for health systems to advance system-level implementation.

Plain language summary: Health systems increasingly need to implement complex practice changes such as the routine capture of patient-reported outcome (PRO) measures. Yet these system-level changes can be challenging to manage given the variability in practice sites and implementation context across the system at large. We utilized a systems engineering method-structured analysis and design technique-to develop a generalizable diagram of PRO workflow that captures five common workflow activities: deploying PRO measures, collecting PRO data, tracking PRO completion, reviewing PRO results, and documenting PRO data for future use. Next, we used the PRO workflow diagram to guide our implementation of PROs for depression care in multiple clinic

Background: Clinical supervision is a common quality assurance method for supporting the implementation and sustainment of evidence-based interventions (EBIs) in community mental health settings. However, assessing and supporting supervisor fidelity requires efficient and effective measurement methods. This study evaluated two observational coding approaches that are potentially more efficient than coding full sessions: a randomly selected 15-min segment and the first case discussion of the session.

Method: Data were leveraged from a randomized trial of an Audit and Feedback (A&F) intervention for supervisor Adherence and Competence. Supervisors (N = 57) recorded and uploaded weekly group supervision sessions for 7 months, with one session observationally coded each month (N = 374). Of the coded sessions, one was randomly selected for each supervisor, and a random 15-min segment was coded. Additionally, the first case discussion was coded for the full sample of sessions.

Results: Across all models (and controlling for the proportion of the session covered by the partial observation), Adherence and Competence scores from partial observations were positively and significantly associated with scores from full sessions. In all cases, partial observations were most accurate when the level of Adherence and Competence was moderate. At lower levels, partial observations were underestimates, and at higher levels, they were overestimates.

Conclusions: The results suggest that efficient observational measurement can be achieved while retaining a general level of measurement effectiveness. Practically, first-case discussions are easier to implement, whereas 15-min segments have fewer potential threats to validity. Evaluation of resource requirements is needed, along with determining whether A&F effects are retained if feedback is based on partial observations. Nevertheless, more efficient observational coding could increase the feasibility of routine fidelity monitoring and quality assurance strategies, including A&F, which ultimately could support the implementation and sustainment of effective supervision practices and EBIs in community practice settings.Plain Language Summary: When delivering evidence-based mental health interventions in community-based practice settings, a common quality assurance method is clinical supervision. To support supervisors, assessment methods are needed, and those methods need to be both efficient and effective. Ideally, supervision sessions would be recorded, and trained coders would rate the supervisor's use of specific strategies. In most settings, though, this requires too many resources. The present study evaluated a more efficient approach. The data came from an existing randomized trial of an Audit and Feedback intervention for enhancing supervisor Adherence and Competence. This included 57 supervisors and 374

Background: Up to half of low-income mothers experience symptoms of depression and anxiety that affect their well-being and increase their children's risk for behavioral and emotional problems. To address this problem, an engaged research/practice planning team designed the Mental Health Innovation (MHI), a multicomponent implementation strategy that integrates evidence-based mental health interventions within the national Nurse-Family Partnership (NFP). The MHI includes four implementation strategies: online training modules, clinical resources, team meeting modules, and virtual consultation.

Methods: A convergent, mixed methods observational design was applied to evaluate implementation outcomes, guided by the RE-AIM framework. We operationalized Reach as the number and demographics of women enrolled in NFP agencies exposed to MHI strategies. Adoption was operationalized as the number and proportion of nurses and supervisors who used MHI implementation strategies. For implementation, we assessed multilevel stakeholders' perceptions of strategy acceptability and feasibility. Data were pulled from NFP's national data management systems and collected through focus groups and surveys. Quantitative data were analyzed using counts and summary statistics. Qualitative themes were generated through content analysis.

Results: The MHI reached agencies serving 51,534 low-income mothers (31.2% African American and 30.0% Latina). Adoption rates varied across implementation strategies. Between 60% and 76% of NFP nurses (N = 2,100) completed each online module. Between 27% and 51% of nurse supervisors (n = 125) reported using each team meeting module. Of 110 teams invited to participate in virtual consultation, 40.9% (n = 45) participated. Mothers served by agencies participating in virtual consultation differed significantly from those who did not, with lower percentages of African American and Latina. Qualitative themes suggest that MHI strategies were generally viewed as acceptable; perceptions of feasibility varied across strategies.

Conclusions: This study identified both strengths and opportunities for improvement. Further evaluation is needed to assess the MHI's effectiveness in improving mothers' mental health.

Background Implementation mechanisms are defined as processes or events through which implementation strategies operate to affect one or more implementation outcomes. Understanding the mechanisms through which implementation strategies work is critical to understanding how and why implementation efforts are successful, and to matching, tailoring, and optimizing implementation strategies. This study examined the content of abstracts included in the program for the 2019 Society for Implementation Research Collaboration (SIRC) conference to characterize the presence of data related to implementation strategy mechanisms and their larger causal pathways. Methods Trained coders reviewed all 205 accepted abstracts and extracted information regarding discrete implementation strategies, determinants of implementation, implementation mechanisms, service outcomes, and implementation outcomes. Theoretical articles were omitted from further analyses due to their inability to offer data related to implementation mechanisms. Results Of the 151 empirical studies included, only 11 (7.28%) reported studying mechanisms. Mechanisms were examined in projects utilizing 14 different implementation strategies. We were able to construct implementation causal pathways for just two implementation strategies, "assess for readiness and identify determinants," representing information pulled from four different abstracts, and "create a learning collaborative," with data pulled from just one abstract. Conclusions These findings indicate that, at least based on SIRC conference abstracts, the empirical investigation of implementation mechanisms remains understudied, highlighting the need for focused research on the study of mechanisms. Plain Language Summary Understanding the mechanisms through which implementation strategies work is critical to understanding how and why implementation efforts are successful. The study of implementation mechanisms may be used to optimize implementation strategy decisions. Investigations to date have not established causal pathways linking implementation strategies, mechanisms, barriers, and outcomes. This study examined abstracts included in the program for the 2019 Society for Implementation Research Collaboration (SIRC) conference. Trained coders reviewed all 205 accepted abstracts and extracted information to characterize the presence of data related to implementation strategy causal pathways. A minority of abstracts reported studying mechanisms. We were able to construct implementation causal pathways for just two implementation strategies, representing information pulled from five different abstracts all together. This highlights the need for focused research on the study of mechanisms.

Background: Implementation climate is an organizational construct theorized to facilitate the adoption and delivery of evidence-based practices. Within schools, teachers often are tasked with implementing universal prevention programs. Therefore, they are ideal informants when assessing school implementation climate for initial and continuous implementation improvement efforts. The purpose of this study was to examine the construct validity (i.e., factor structure and convergent/divergent validity) of a school-adapted measure of strategic implementation climate called the School Implementation Climate Scale (SICS).

Methods: Confirmatory factor analyses of SICS data, collected from 441 teachers in 52 schools, were used to compare uncorrelated and correlated first-order factor models and a second-order hierarchical model. Correlations with other school measures were examined to assess SICS convergent and divergent validities.

Results: Results demonstrated acceptable internal consistency for each SICS subscale (αs > 0.80 for all subscales) and construct validity of the hypothesized factor structure of the SICS with three new scales. The hierarchical second-order factor structure with eight first-order factors was found to best model the SICS data. Correlations with other school measures were in the expected direction and magnitude.

Conclusions: Results from this study provide psychometric evidence that supports the use of the SICS to inform the implementation research and practice in schools.

Plain language summary: Schools are busy trying to implement various universal programs and systems to help support kids in their growth. Beginning and sustaining these efforts is quite challenging, and there is need for tools and ideas to help those implementation efforts. One concept is implementation climate, which is broadly the school staff's perception of the implementation support for a given practice. However, no measure currently exists to help schools assess their implementation climate. The goal of our study was to adapt a measure of implementation climate used in other settings to the school environment. We used feedback from educational experts to make changes and used various analyses to determine if the newly adapted measure was psychometrically sound. Findings suggest the new measure is usable to guide implementation efforts in schools.

Background: A national shortage of mental health providers for youth exists in the United States. Implementation support for mental health services in schools, where students are most likely to access care, can help to fill these gaps. Coaching consists of in vivo modeling and support during service delivery and is effective in supporting the implementation of evidence-based practices (EBPs). This implementation report describes the recruitment and training of community providers to become coaches as a part of a modified train-the-trainer model of implementation support. Method: An EBP implementation program, Transforming Research into Action to Improve the Lives of Students (TRAILS), trained community providers in Michigan to increase knowledge of cognitive behavioral therapy (CBT) and position them as coaches in schools. The development of the coach network involved five stages prior to the initiation of a randomized controlled trial: (1) recruitment, (2) a one-day clinical training, (3) 12 weeks of individualized consultation, (4) evaluation, and (5) training in the coaching protocol. Results: A total of 347 individuals attended an initial training, and 187 were paired with a consultant. Eighty-six clinicians from 47 of Michigan's 83 counties successfully became coaches by completing all required elements of training. Coaches showed significant improvements in the use and knowledge of CBT across consultation. Conclusion: Statewide networks of trained mental health professionals can address gaps in mental healthcare for youth. This article demonstrates one strategy for strengthening and leveraging community expertise to support the implementation of EPBs in schools.

Plain language summary: Although youth face many barriers in accessing effective mental health care, schools are one setting where they can more easily receive treatment. Research shows that training and supports are needed for school mental health professionals to provide effective care. Coaching, which involves in vivo support for school mental health professionals, is one helpful strategy. We describe the process of recruiting and training community clinicians to become coaches. The Transforming Research into Action to Improve the Lives of Students (TRAILS) program successfully recruited and trained a network of 86 community clinicians to become coaches. Clinicians attended two day-long trainings and participated in 12 weeks of personalized consultation. Clients to whom these clinicians provided CBT showed significant symptom improvement. Clinicians also reported that they increased their knowledge and use of core CBT strategies, including psychoeducation, exposure, and behavioral activation. Community mental health professionals who are trained as coaches can address gaps in access to care for youth. We demonstrate one strategy for strengthening and leveraging clinicians' knowledge of CBT to support the schoo