Abstract
BackgroundEthnography has been proposed as a valuable method for understanding how implementation occurs within dynamic healthcare contexts, yet this method can be time-intensive and challenging to operationalize in pragmatic implementation. The current study describes an ethnographically-informed method of guided discussions developed for use by a multi-project national implementation program.MethodsThe EMPOWER QUERI is conducting three projects to implement innovative care models in VA women’s health for high-priority health concerns – prediabetes, cardiovascular risk, and mental health – utilizing the Replicating Effective Programs (REP) implementation strategy enhanced with stakeholder engagement and complexity science. Drawing on tenets of ethnographic research, we developed a lightly-structured method of guided “periodic reflections” to aid in documenting implementation phenomena over time. Reflections are completed as 30–60 min telephone discussions with implementation team members at monthly or bi-monthly intervals, led by a member of the implementation core. Discussion notes are coded to reflect key domains of interest and emergent themes, and can be analyzed singly or in triangulation with other qualitative and quantitative assessments to inform evaluation and implementation activities.ResultsThirty structured reflections were completed across the three projects during a 15-month period spanning pre-implementation, implementation, and sustainment activities. Reflections provide detailed, near-real-time information on projects’ dynamic implementation context, including characteristics of implementation settings and changes in the local or national environment, adaptations to the intervention and implementation plan, and implementation team sensemaking and learning. Reflections also provide an opportunity for implementation teams to engage in recurring reflection and problem-solving.ConclusionsTo implement new, complex interventions into dynamic organizations, we must better understand the implementation process as it unfolds in real time. Ethnography is well suited to this task, but few approaches exist to aid in integrating ethnographic insights into implementation research. Periodic reflections show potential as a straightforward and low-burden method for documenting events across the life cycle of an implementation effort.They offer an effective means for capturing information on context, unfolding process and sensemaking, unexpected events, and diverse viewpoints, illustrating their value for use as part of an ethnographically-minded implementation approach.Trial registrationThe two implementation research studies described in this article have been registered as required: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans (NCT02991534); and Implementation of Tailored Collaborative Care for Women Veterans (NCT02950961).
Highlights
Sets stage for core goals of observing, documenting, and reflecting onGoals and Focus: These reflections are intended to provide an opportunity implementation-related events and phenomena
EMPOWER includes three projects to implement innovative care models in Veterans Affairs (VA) women’s health using Replicating Effective Programs (REP), an evidence-based implementation strategy [30,31,32] enhanced with stakeholder engagement [33] and complexity science [13, 21, 34, 35]
Following the lead of prior studies using structured templates to guide discussions or written reports as part of ethnographically-informed implementation evaluation [15, 27, 50], we developed a preliminary template for guided discussions, tailored for use in telephone conversations occurring at monthly or bi-monthly intervals across the EMPOWER projects
Summary
Sets stage for core goals of observing, documenting, and reflecting onGoals and Focus: These reflections are intended to provide an opportunity implementation-related events and phenomena. Periodic reflections provide a means to gather repeated, consecutive information regarding implementation events and conditions occurring at specific moments over the course of an implementation effort. Healthcare settings themselves vary greatly in size, scope, and populations served, and are inherently multi-level and dynamic, providing a context and ecology into which any new intervention must fit. In light of these challenges, achieving uptake of evidence-based practices is almost inevitably a complex undertaking [5]. The answer clearly lies in careful observation and documentation as part of implementation research [7, 9], but few methods have been proposed to address this challenge, in the context of multi-site implementation trials
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