The "good enough" facilitator: elucidating the role of working alliance in the mechanism of facilitation.

Background: While facilitation is a widely used implementation strategy with proven effectiveness, the development of the facilitator-recipient relationship, i.e., working alliance, has received limited attention. However, we hypothesize that working alliance may be part of the mechanism by which facilitation activates change. This study aimed to examine the associations between working alliance, facilitation, and change in clinical care in a hybrid type 3 trial of a manualized intervention, Getting to Implementation (GTI).

Methods: This concurrent triangulation mixed-methods study was conducted at 12 sites in a stepped-wedge trial. We collected surveys using the Working Alliance Inventory-Short instrument (WAI), which includes three subscales of goal alignment, task alignment, and affective bond, from three respondent types (clinical facilitator, evaluation facilitator, and site team members) after a year of intervention. Facilitation activity type and dose were tracked. Summative qualitative interviews with site champions and facilitators) elicited perceptions on working alliance, facilitation, and experiences with the intervention, and results were triangulated with statistical bivariate analyses. The associations between WAI and facilitation time, fidelity, and change in liver cancer screening rate (the primary trial outcome) were assessed.

Results: Across 12 sites, facilitators and site team members completed 21 interviews and 40 WAI surveys, with site aggregate average working alliance scores of 5.9 ± 0.4 on a seven-point scale. Bond scores were highest (6.1 ± 0.5), followed by Goal (6.0 ± 0.4) and Task (5.8 ± 0.5) scores. Overall and subscale scores differed by respondent type, with site respondents consistently rating items higher than facilitators, particularly in Task items. Fidelity to the GTI process (e.g., timely completion of steps and tools) was significantly positively associated with WAI scores overall (r = 0.41, p = 0.007) and subscale scores, including Goal (r = 0.39, p = 0.011), Task (r = 0.42, p = 0.006), and Bond (r = 0.33, p = 0.039). WAI scores were not correlated with facilitation time (dose). WAI scores overall and the Bond and Goal scores were significantly positively associated with sustained improvement in cancer screening rates (r = 0.57, p = 0.015).

Conclusions: In this implementation trial, working alliance between site teams and facilitators was positively associated with both fidelity and cancer screening outcomes and was notably independent of time spent providing facilitation. Findings highlight the importance of working alliance in implementation studies.

Trial registration: This project was registered at ClinicalTrials.Gov ( NCT04178096 ) on 4/29/20.