Implementation of clinical practice changes in the PICU: a qualitative study using and refining the iPARIHS framework

Katherine M Steffen,Mackenzie A Ford,Enola K Proctor,Grace M Lee,Steven M Asch,Laura M Holdsworth

doi:10.1186/s13012-021-01080-9

Abstract

BackgroundLike in many settings, implementation of evidence-based practices often fall short in pediatric intensive care units (PICU). Very few prior studies have applied implementation science frameworks to understand how best to improve practices in this unique environment. We used the relatively new integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to assess practice improvement in the PICU and to explore the utility of the framework itself for that purpose.MethodsWe used the iPARIHS framework to guide development of a semi-structured interview tool to examine barriers, facilitators, and the process of change in the PICU. A framework approach to qualitative analysis, developed around iPARIHS constructs and subconstructs, helped identify patterns and themes in provider interviews. We assessed the utility of iPARIHS to inform PICU practice change.ResultsFifty multi-professional providers working in 8 U.S. PICUs completed interviews. iPARIHS constructs shaped the development of a process model for change that consisted of phases that include planning, a decision to adopt change, implementation and facilitation, and sustainability; the PICU environment shaped each phase. Large, complex multi-professional teams, and high-stakes work at near-capacity impaired receptivity to change. While the unit leaders made decisions to pursue change, providers’ willingness to accept change was based on the evidence for the change, and provider’s experiences, beliefs, and capacity to integrate change into a demanding workflow. Limited analytic structures and resources frustrated attempts to monitor changes’ impacts. Variable provider engagement, time allocated to work on changes, and limited collaboration impacted facilitation. iPARIHS constructs were useful in exploring implementation; however, we identified inter-relation of subconstructs, unique concepts not captured by the framework, and a need for subconstructs to further describe facilitation.ConclusionsThe PICU environment significantly shaped the implementation. The described process model for implementation may be useful to guide efforts to integrate changes and select implementation strategies. iPARIHS was adequate to identify barriers and facilitators of change; however, further elaboration of subconstructs for facilitation would be helpful to operationalize the framework.Trial registrationNot applicable, as no health care intervention was performed.

Highlights

Like in many settings, implementation of evidence-based practices often fall short in pediatric intensive care units (PICU)
Through exploration of the iPARIHS framework’s innovation, recipient, context, and facilitation constructs, we identified six themes and nine sub-themes that were important for change in the PICU
A model for implementing change in the PICU Through exploration of the iPARIHS framework’s constructs and identification of the themes described above, we developed a model for change implementation in the PICU (Fig. 1)

Summary

Introduction

Implementation of evidence-based practices often fall short in pediatric intensive care units (PICU). As in many health care settings, implementation of evidence in the intensive care unit (ICU) presents challenges, some of which may be due to patient complexity, stress, and an increased risk for error [2]. Prior studies report that identifying and addressing local, contextual implementation barriers may help to optimize care delivery in the ICU [12,13,14], which include lack of awareness of the innovation/guideline [7, 15], lack of resources [11], competing priorities [11], apprehension around change [7], poor formatting of the innovation for the clinical context [7], and inability to provide accurate feedback on performance [11]. Other studies identified engaging staff, education, providing adequate time and resources, reminders, audit and feedback, and data reporting on performance as being useful implementation strategies [5, 6, 8, 9, 15, 16], with providers in different roles reporting different implementation strategies most useful in effecting change [15]

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