External Facilitation Research Articles

Overcoming Barriers in Hospital-Based Health Technology Assessment (HB-HTA): International Expert Panel Consensus.

The purpose of this article is to investigate the common facilitators and barriers associated with the implementation of hospital-based health technology assessment (HB-HTA) across diverse hospital settings in seven countries. Through a two-round Delphi study, insights were gathered from a panel of 15 HTA specialists from France, Hungary, Italy, Kazakhstan, Poland, Switzerland, and Ukraine. Experts initially conducted a comprehensive review of the HB-HTA implementation in their respective countries, identifying the barriers and facilitators through descriptive analysis. Subsequently, panel experts ranked these identified barriers and facilitators on a seven-point Likert scale. A median agreement score ≥ 6 and interquartile range (IQR) ≤ 1 was accepted as reaching a consensus. Out of the 12 statements categorized as external and internal barriers and facilitators, the expert panel reached consensus on six statements (two barriers and four facilitators). The external barrier, which achieved consensus, was the lack of the formal recognition of the role of HB-HTA in national or regional legislations. The internal barrier reaching consensus was the limited availability of human resources dedicated to HB-HTA. This qualitative study indicates that HB-HTA still has progress to make before being formally accepted and integrated across most countries, although by building on the facilitating factors we identified there may be an opportunity for the implementation of internationally developed strategies to strengthen HB-HTA practices.

A trial of implementation facilitation to increase timely admission to methadone treatment

BackgroundDuring the ongoing opioid epidemic, some Opioid Treatment Programs (OTPs) are unable to admit program applicants in a timely fashion. Interim methadone (IM) treatment (without routine counseling) is an effective approach to overcome this challenge when counseling capacity is inadequate to permit admissions within 14 days of request. It requires both federal and state approval and has been rarely utilized since its incorporation into the federal OTP regulations in 1993. MethodsWe evaluated the impact of Implementation Facilitation (IF) on OTPs providing timely admission to methadone treatment (i.e., within 14 days of request), adopting IM, and changing admissions procedures. IF included data collection on admission processes and an external facilitator who engaged OTP leadership, Local Champions through site visits, remote academic detailing, and feedback. Local Champions and State Opioid Treatment Authorities (SOTAs) participated in learning collaboratives. Using a modified stepped wedge design, six OTPs in four US states on the east and west coasts were randomly assigned to one of two clusters that staggered the timing of IF receipt. Study Phases included: Pre-Implementation, IF, and Sustainability. OTPs submitted data on treatment requests and admissions for 28 months (N = 3108 requests for treatment). ResultsAlthough none of the OTPs adopted IM, all six developed policies and procedures to enable its use. Some OTPs streamlined admissions processes prior to study launch and during the IF intervention. OTPs reduced admission delays over time, although there was substantial site heterogeneity. The IF Phase for the early cluster coincided with the onset of COVID-19, complicating the study. Rates of timely admission within 14 days of request were 56.2 % (Pre-Implementation), 55.8 % (IF), and 78.8 % (Sustainability). Compared to the Pre-Implementation Phase, the odds of timely admission were not significantly different during the IF Phase but significantly higher during the Sustainability Phase (OR = 2.35 [95 % CI = 1.34, 4.12]; p = 0.003). ConclusionsCommitting to study participation and IF activities may have prompted some OTPs to change practices that improved timely admission. Attributing changes to IF should be done with caution considering study limitations. Data collection for the study spanned the COVID-19 pandemic, which complicates interpretation. Trial registrationClinicaltrials.gov registration # NCT04188977.

Facilitating Evidence-Based Practice among Nurses in a Tertiary General Hospital: A Six-Year Practice of an Implementation Strategy Informed by the i-PARIHS Framework

Aims. To develop an evidence-based practice (EBP) facilitating strategy informed by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and evaluates the strategy’s effectiveness on promoting EBP. Background. Nurses are increasingly expected to use research evidence in practice to improve patients’ outcomes, but the application of such evidence is still unsatisfactory. The facilitation of EBP in nursing needs the organization and the individual levels. Methods. Based on an analysis of EBP-promoting strategies and expert consultation, the core team of the nursing department developed an EBP group-based and project-oriented strategy under the guidance of the i-PARIHS framework. The strategy was implemented for six years and evaluated by a longitudinal design. The validated Chinese version of the self-reported Evidence Based Practice Questionnaire (EBPQ) was used to assess the attitudes, knowledge, and practice of the nurses. Results. The mean score of the total EBPQ was 4.46 (SD = 0.92) after one year of the EBP strategy, and the scores for knowledge, attitudes, and practice of EBP members were higher than those of general nurses p<0.05. After four years, EBP members’ scores continued to increase. EBP groups conducted 51 EBP projects in the areas of emergency nursing, surgical and medical nursing, critical care, and so forth. Of these, 33 projects improved nursing practice by changing nursing procedures, upgrading nursing tools, and developing nursing standards, resulting in improved patient outcomes. Conclusion. The EBP group-based and project-oriented strategy can promote EBP. The composition of the EBP group, the annual audit of EBP projects, and the roles of internal and external facilitators were key components of this EBP-facilitating strategy. Implications for Nursing Management. The strategy is an organizational-level EBP-facilitation approach which can improve nurses’ academic preparation for EBP through ongoing training and sustained EBP behavior that involves annual projects.

Implementation of medication reviews in community pharmacy: reaching consensus on stakeholders’ recommendations for mechanisms of change using the nominal group technique

BackgroundSince 2022, patients with five or more medicines are eligible for a medication review (MR) in a community pharmacy remunerated by the German health system. However, implementation has been slow, with few pharmacies providing MRs. Stakeholders’ input is necessary to detail how implementation strategies can be executed effectively on a national level. Prior research identified “external facilitation” and “altering incentives” as crucial strategies to achieve implementation outcomes.AimTo gather stakeholders’ recommendations for, and obtain consensus on, mechanisms of change that allow implementation strategies to work in practice.MethodThe consensus method used was the nominal group technique (NGT) with NGT-discussions held separately with pharmacy owners and pharmacy chambers employees. Votes were summed and the relative importance (rI) calculated, defined as (score achieved for a mechanism)/(maximum possible score) × 100. Content analysis provided context for the highest ranked mechanisms and allowed linking to implementation outcomes.ResultsFour NGT-discussions were held in 2023 (n = 2 owners; n = 2 chamber employees) with a total of 17 participants. The overall highest ranked mechanisms were fit-for-purpose software (rI = 154.7) detailed process support (rI = 104.9) and an expert support line (rI = 77.7). These together with financial viability (rI = 40.0) were prioritised by both participant groups. Three mechanisms were favoured for both implementation strategies, namely software, process support and materials (rI = 34.3).ConclusionThis study identified stakeholders’ priorities for mechanisms of change to implement MRs in community pharmacies. Focusing efforts on the prioritised mechanisms is likely to significantly advance a national implementation plan for countries which are at an early implementation stage.

An implementation strategy postmortem method developed in the VA rural Transitions Nurse Program to inform spread and scale-up.

High-quality implementation evaluations report on intervention fidelity and adaptations made, but a practical process for evaluating implementation strategies is needed. A retrospective method for evaluating implementation strategies is also required as prospective methods can be resource intensive. This study aimed to establish an implementation strategy postmortem method to identify the implementation strategies used, when, and their perceived importance. We used the rural Transitions Nurse Program (TNP) as a case study, a national care coordination intervention implemented at 11 hospitals over three years. The postmortem used a retrospective, mixed method, phased approach. Implementation team and front-line staff characterized the implementation strategies used, their timing, frequency, ease of use, and their importance to implementation success. The Expert Recommendations for Implementing Change (ERIC) compilation, the Quality Enhancement Research Initiative phases, and Proctor and colleagues' guidance were used to operationalize the strategies. Survey data were analyzed descriptively, and qualitative data were analyzed using matrix content analysis. The postmortem method identified 45 of 73 ERIC strategies introduced, including 41 during pre-implementation, 37 during implementation, and 27 during sustainment. External facilitation, centralized technical assistance, and clinical supervision were ranked as the most important and frequently used strategies. Implementation strategies were more intensively applied in the beginning of the study and tapered over time. The postmortem method identified that more strategies were used in TNP than planned and identified the most important strategies from the perspective of the implementation team and front-line staff. The findings can inform other implementation studies as well as dissemination of the TNP intervention.

Protocol for a parallel cluster randomized trial of a participatory tailored approach to reduce overuse of antibiotics at hospital discharge: the ROAD home trial

BackgroundAntibiotic overuse at hospital discharge is common, costly, and harmful. While discharge-specific antibiotic stewardship interventions are effective, they are resource-intensive and often infeasible for hospitals with resource constraints. This weakness impacts generalizability of stewardship interventions and has health equity implications as not all patients have access to the benefits of stewardship based on where they receive care. There may be different pathways to improve discharge antibiotic prescribing that vary widely in feasibility. Supporting hospitals in selecting interventions tailored to their context may be an effective approach to feasibly reduce antibiotic overuse at discharge across diverse hospitals. The objective of this study is to evaluate the effectiveness of the Reducing Overuse of Antibiotics at Discharge Home multicomponent implementation strategy (“ROAD Home”) on antibiotic overuse at discharge for community-acquired pneumonia and urinary tract infection.MethodsThis 4-year two-arm parallel cluster-randomized trial will include three phases: baseline (23 months), intervention (12 months), and postintervention (12 months). Forty hospitals recruited from the Michigan Hospital Medicine Safety Consortium will undergo covariate-constrained randomization with half randomized to the ROAD Home implementation strategy and half to a “stewardship as usual” control. ROAD Home is informed by the integrated-Promoting Action on Research Implementation in Health Services Framework and includes (1) a baseline needs assessment to create a tailored suite of potential stewardship interventions, (2) supported decision-making in selecting interventions to implement, and (3) external facilitation following an implementation blueprint. The primary outcome is baseline-adjusted days of antibiotic overuse at discharge. Secondary outcomes include 30-day patient outcomes and antibiotic-associated adverse events. A mixed-methods concurrent process evaluation will identify contextual factors influencing the implementation of tailored interventions, and assess implementation outcomes including acceptability, feasibility, fidelity, and sustainment.DiscussionReducing antibiotic overuse at discharge across hospitals with varied resources requires tailoring of interventions. This trial will assess whether a multicomponent implementation strategy that supports hospitals in selecting evidence-based stewardship interventions tailored to local context leads to reduced overuse of antibiotics at discharge. Knowledge gained during this study could inform future efforts to implement stewardship in diverse hospitals and promote equity in access to the benefits of quality improvement initiatives.Trial registrationClinicaltrials.gov NCT06106204 on 10/30/23

Digital Technology as a Tool for Changing Learning Space for Workers’ Training in Nigeria

Workers are essential part of the organisational system because they represent the human capital resources that drive all other factors or parts of the system in a bid to achieve the organizational goal. In order to keep the workers abreast of changes and to ensure acquisition of requisite skills needed for optimal performance, there is always the need to engage the workers in training and retraining from time to time. Organization of trainings for workers come in different forms and types. There could be on the job training where workers are exposed to learning components while on duty at work. There could also be organization of training outside the workplace when workers take time off to undergo trainings which will help in additional skill acquisition. Facilitators used for workers training can either be internal or external facilitators depending on the needs and choice of organisers. However, with the emergence of technology and the recent occurrence like the world pandemic which nearly stopped all activities even at the workplace, there have been many evolutions on how activities at workplace can be carried out. This is also inclusive of training process which can afford the workers the opportunity to learn and improve their skills inspite of the limitations prevalent in the world. One would then think of exploring digital training for workers in Nigeria. This paper looks at the need for a change of learning space for Nigerian workers, opportunities in digital training, challenges of digital technology at the workplace for training and some suggestions on how to maximize the benefits for training Nigerian workers.

Impact of Evidence-Based Quality Improvement on Tailoring VA’s Patient-Centered Medical Home Model to Women Veterans’ Needs

BackgroundWomen Veterans’ numerical minority, high rates of military sexual trauma, and gender-specific healthcare needs have complicated implementation of comprehensive primary care (PC) under VA’s patient-centered medical home model, Patient Aligned Care Teams (PACT).ObjectiveWe deployed an evidence-based quality improvement (EBQI) approach to tailor PACT to meet women Veterans’ needs and studied its effects on women’s health (WH) care readiness, team-based care, and burnout.DesignWe evaluated EBQI effectiveness in a cluster randomized trial with unbalanced random allocation of 12 VAMCs (8 EBQI vs. 4 control). Clinicians/staff completed web-based surveys at baseline (2014) and 24 months (2016). We adjusted for individual-level covariates (e.g., years at VA) and weighted for non-response in difference-in-difference analyses for readiness and team-based care overall and by teamlet type (mixed-gender PC-PACTs vs. women-only WH-PACTs), as well as post-only burnout comparisons.ParticipantsWe surveyed all clinicians/staff in general PC and WH clinics.InterventionEBQI involved structured engagement of multilevel, multidisciplinary stakeholders at network, VAMC, and clinic levels toward network-specific QI roadmaps. The research team provided QI training, formative feedback, and external practice facilitation, and support for cross-site collaboration calls to VAMC-level QI teams, which developed roadmap-linked projects adapted to local contexts.Main MeasuresWH care readiness (confidence providing WH care, self-efficacy implementing PACT for women, barriers to providing care for women, gender sensitivity); team-based care (change-readiness, communication, decision-making, PACT-related QI, functioning); burnout.Key ResultsOverall, EBQI had mixed effects which varied substantively by type of PACT. In PC-PACTs, EBQI increased self-efficacy implementing PACT for women and gender sensitivity, even as it lowered confidence. In contrast, in WH-PACTs, EBQI improved change-readiness, team-based communication, and functioning, and was associated with lower burnout.ConclusionsEBQI effectiveness varied, with WH-PACTs experiencing broader benefits and PC-PACTs improving basic WH care readiness. Lower confidence delivering WH care by PC-PACT members warrants further study.Trial RegistrationThe data in this paper represent results from a cluster randomized controlled trial registered in ClinicalTrials.gov (NCT02039856).

Sustaining the collaborative chronic care model in outpatient mental health: a matrixed multiple case study.

Sustaining evidence-based practices (EBPs) is crucial to ensuring care quality and addressing health disparities. Approaches to identifying factors related to sustainability are critically needed. One such approach is Matrixed Multiple Case Study (MMCS), which identifies factors and their combinations that influence implementation. We applied MMCS to identify factors related to the sustainability of the evidence-based Collaborative Chronic Care Model (CCM) at nine Department of Veterans Affairs (VA) outpatient mental health clinics, 3-4years after implementation support had concluded. We conducted a directed content analysis of 30 provider interviews, using 6 CCM elements and 4 Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) domains as codes. Based on CCM code summaries, we designated each site as high/medium/low sustainability. We used i-PARIHS code summaries to identify relevant factors for each site, the extent of their presence, and the type of influence they had on sustainability (enabling/neutral/hindering/unclear). We organized these data into a sortable matrix and assessed sustainability-related cross-site trends. CCM sustainability status was distributed among the sites, with three sites each being high, medium, and low. Twenty-five factors were identified from the i-PARIHS code summaries, of which 3 exhibited strong trends by sustainability status (relevant i-PARIHS domain in square brackets): "Collaborativeness/Teamwork [Recipients]," "Staff/Leadership turnover [Recipients]," and "Having a consistent/strong internal facilitator [Facilitation]" during and after active implementation. At most high-sustainability sites only, (i) "Having a knowledgeable/helpful external facilitator [Facilitation]" was variably present and enabled sustainability when present, while (ii) "Clarity about what CCM comprises [Innovation]," "Interdisciplinary coordination [Recipients]," and "Adequate clinic space for CCM team members [Context]" were somewhat or less present with mixed influences on sustainability. MMCS revealed that CCM sustainability in VA outpatient mental health clinics may be related most strongly to provider collaboration, knowledge retention during staff/leadership transitions, and availability of skilled internal facilitators. These findings have informed a subsequent CCM implementation trial that prospectively examines whether enhancing the above-mentioned factors within implementation facilitation improves sustainability. MMCS is a systematic approach to multi-site examination that can be used to investigate sustainability-related factors applicable to other EBPs and across multiple contexts.

Using data from mHealth apps to inform person-centred practice: A discussion paper

Background mHealth applications (apps) are tools that can enhance research by efficiently collecting and storing large amounts of data. However, data collection alone does not lead to change. Innovation and practice change occur through utilisation of evidence. The volume of data collected raises questions regarding utilisation of data by nurses and midwives, and how data from mHealth apps can be used to improve person-centred practice. There is limited empirical evidence and a lack of direction from global health authorities to guide nurses and midwives in this area. Aim To describe strategies for nurses and midwives that could enhance the effective use of data generated by mHealth apps to inform person-centred practice. The purpose of this paper is to stimulate reflection and generate actions for data utilisation when using mHealth apps in nursing research and practice. Methods This discussion paper has been informed by current evidence, the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, and research experience as part of doctoral study. Findings Before engaging in data collection using mHealth apps, nurses and midwives would benefit from considering the nature of the evidence collected, available technological infrastructure, and staff skill levels. When collecting data and interpreting results, use of a team approach supported by engaged leadership and external facilitation is invaluable. This provides support to operate apps, and more importantly use the data collected to inform person-centred practice. Conclusions This paper addresses the limited available evidence to guide nurses and midwives when using mHealth apps to collect and use data to inform practice change. It highlights the need for appropriate technology, external facilitative support, engaged leadership, and a team approach to collect meaningful evidence using mHealth apps. Clinicians, leaders, and researchers can apply the strategies provided to enhance the use of mHealth apps and ensure translation of evidence into practice.

Diffusion of excellence: evaluating a system to identify, replicate, and spread promising innovative practices across the Veterans health administration.

The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program provides a system to identify, replicate, and spread promising practices across the largest integrated healthcare system in the United States. DoE identifies innovations that have been successfully implemented in the VHA through a Shark Tank style competition. VHA facility and regional directors bid resources needed to replicate promising practices. Winning facilities/regions receive external facilitation to aid in replication/implementation over the course of a year. DoE staff then support diffusion of successful practices across the nationwide VHA. Organized around the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework, we summarize results of an ongoing long-term mixed-methods implementation evaluation of DoE. Data sources include: Shark Tank application and bid details, tracking practice adoptions through a Diffusion Marketplace, characteristics of VHA facilities, focus groups with Shark Tank bidders, structured observations of DoE events, surveys of DoE program participants, and semi-structured interviews of national VHA program office leaders, VHA healthcare system/facility executives, practice developers, implementation teams and facilitators. In the first eight Shark Tanks (2016-2022), 3,280 Shark Tank applications were submitted; 88 were designated DoE Promising Practices (i.e., practices receive facilitated replication). DoE has effectively spread practices across the VHA, with 1,440 documented instances of adoption/replication of practices across the VHA. This includes 180 adoptions/replications in facilities located in rural areas. Leadership decisions to adopt innovations are often based on big picture considerations such as constituency support and linkage to organizational goals. DoE Promising Practices that have the greatest national spread have been successfully replicated at new sites during the facilitated replication process, have close partnerships with VHA national program offices, and tend to be less expensive to implement. Two indicators of sustainment indicate that 56 of the 88 Promising Practices are still being diffused across the VHA; 56% of facilities originally replicating the practices have sustained them, even up to 6 years after the first Shark Tank. DoE has developed a sustainable process for the identification, replication, and spread of promising practices as part of a learning health system committed to providing equitable access to high quality care.

Communities catalyzing change with data to mitigate an invisible menace, traffic-related air pollution

ObjectivesTo identify strategies and tactics communities use to translate research into environmental health action.MethodsWe employed a qualitative case study design to explore public health action conducted by residents, organizers, and public health planners in two Massachusetts communities as part of a community based participatory (CBPR) research study. Data sources included key informant interviews (n = 24), reports and direct observation of research and community meetings (n = 10) and project meeting minutes from 2016–2021. Data were coded deductively drawing on the community organizing and implementation frameworks.ResultsIn Boston Chinatown, partners drew broad participation from community-based organizations, residents, and municipal leaders, which resulted in air pollution mitigation efforts being embedded in the master planning process. In Somerville, partners focused on change at multiple levels, developer behavior, and separate from the funded research, local legislative efforts, and litigation.ConclusionsCBPR affords communities the ability to environmental health efforts in a way that is locally meaningful, leveraging their respective strengths. External facilitation can support the continuity and sustainment of community led CBPR efforts.

Empowering underachieving youths in producing videos on social media: a study on the effectiveness of the BE:GINOW Training Programme

This study conducted a detailed analysis of how academically underachieving youth use technology and social media to create videos as part of a training programme called BE:GINOW. A mixed study design that combined a quantitative method using questionnaires and qualitative methods through interviews was used. The questionnaires were distributed through two phases: pre-BE:GINOW programme (Phase 1) and post-BE:GINOW programme (Phase 2), which intended to compare the videos produced by the participants before and after the programme. We also conducted two interview sessions to obtain feedback from external facilitators and participants on the effectiveness of the programme. The results show that BE:GINOW has successfully helped the participants produce more quality videos after eight months of participating in the programme. Respondents agreed that the post-programmed videos were better in terms of presentation structure, message delivery, language use and presentation style. The external facilitators and participants also confirmed the effectiveness of BE:GINOW in motivating and guiding the underachieving youth to improve their skills in the production of videos. It is envisaged that a programme like BE:GINOW will serve as a model for future technology-based training, acting as a catalyst for academic underachievers to expand their life skills and become active content creators.

A Mixed-Methods Study of Compassionate Mind Training for Pupils (CMT-Pupils) as a School-Based Wellbeing Intervention

ObjectivesMental health difficulties in children are increasing, especially following transition from elementary to high-school education. In attempts to mitigate risk of these difficulties, proactive wellbeing interventions are becoming increasingly explored in school settings. Recently, Compassionate Mind Training (CMT) has been shown to be well-accepted and efficacious in promoting school staff wellbeing and prosocial behaviours. This paper outlines the impact of CMT as a pupil wellbeing intervention.MethodSixty-seven pupils aged 11–12 took part in either Personal, Social, Health and Economic (PSHE) lessons as usual (n=30), or CMT-Pupils (n=37) as their PSHE lessons, over a 5-week period. A mixed-methods quantitative and qualitative design was utilised to explore implementation and curricula effectiveness across several wellbeing parameters (e.g., anxiety, self-compassion, perfectionism, moods and feelings, self-esteem).ResultsPupils reported positively on their experiences of the CMT-Pupils lessons, content and practices. Quantitative analyses revealed a significant time-by-group interaction effect for anxiety, reflecting differences in anxiety post CMT-Pupils vs. PSHE as usual. No further interactions reached significance. Qualitative analyses revealed benefits of CMT-Pupils for pupil and classroom behaviour, including emotion regulation, kindness to others and feelings of inclusion. Benefits were also found to extend to the class teachers.ConclusionsCMT-pupils could be a promising school-based wellbeing intervention for improving prosocial behaviours, the classroom environment and protecting against deteriorations in child mental health. Larger scale explorations of CMT-Pupils across wider demographics, including investigation of who can deliver the curriculum efficaciously (e.g., teachers vs. external facilitators), are suggested as next steps for investigation.PreregistrationThis study was not preregistered.

A Case Study on the Effectiveness of SPARSH Project for Deaf-blind Children by the Malankara Social Service Society (MSSS) Trivandrum, Kerala

Purpose of the Study: The case study aims to review the outcome of the SPARSH project in getting a better quality of life for the deaf–blind through NGO intervention. Deaf-blind are those vulnerable children suffering from the absence of hearing and eyesight. This study considers children with varying degrees of vision and hearing loss. It reviews the support system offered by the external trainers and facilitators in transforming the lives of the subjects. It is a case study conducted on children from the city of Thiruvananthapuram based on their stories of transformation. Design/Methodology/Approach: The Study explores first-hand information based on the cases of the beneficiaries through their real-life experiences to assess the intervention and effectiveness of the SPARSH project on their empowerment. The researcher used an interview schedule to gather data from the parents of the beneficiaries. Result and Outcome of the Study: The study describes the effectiveness of the SPARSH project in improving the quality of life of deaf-blind children. It explores the various interventions used to empower the deaf–blind children by training them to face their physical challenges. Originality/Value: This paper presents a couple of case studies by exploring the real-life experiences of beneficiaries concerning the intervention carried out under the SPARSH project. Paper Type: A Case Study

Rural and regional maternity managers’ and educators’ views of the Maternity and Newborn Emergencies (MANE) education program in Victoria, Australia: a qualitative descriptive study

BackgroundAustralia has one of the lowest perinatal morbidity and mortality rates in the world, however a cluster of perinatal deaths at a regional health service in the state of Victoria in 2015 led to state-wide reforms, including the introduction of the Maternity and Newborn Emergencies (MANE) program. MANE was a 2-day interprofessional maternity education program delivered by external expert facilitators to rural and regional Victorian maternity service providers. An independent evaluation found that the MANE program improved the confidence and knowledge of clinicians in managing obstetric emergencies and resulted in changes to clinical practice. While there is a large volume of evidence that supports the use of interprofessional education in improving clinicians’ clinical practice, the impact of these programs on the overall safety culture of a health service has been less studied. Managers and educators have an important role in promoting the safety culture and clinical governance of the heath service. The aim of this study, therefore, was to explore Victorian rural and regional maternity managers’ and educators’ views and experiences of the MANE program.MethodsMaternity managers and educators from the 17 regional and rural health services across Victoria that received the MANE program during 2018 and 2019 were invited to participate. Semi-structured interviews using mostly open-ended questions (and with a small number of fixed response questions) were undertaken. Qualitative data were transcribed verbatim and analysed thematically. Descriptive statistics were used for quantitative data.ResultsTwenty-one maternity managers and educators from the 17 health services participated in the interviews. Overall, participants viewed the MANE program positively. Four themes were identified: the value of external facilitation in providing obstetric emergency training; improved awareness and understanding of clinical governance; improved clinical practice; and the importance of maintaining the program. Participants agreed that MANE had improved the confidence (94%) and skills (94%) of clinicians in managing obstetric emergencies, as well as confidence to escalate concerns (94%), and most agreed that it had improved clinical practice (70%) and teamwork among attendees (82%).ConclusionMaternity managers and educators were positive about MANE; they considered that it contributed to improving factors that impact the safety culture of health services, with delivery by external experts considered to be particularly important. Given the crucial role of maternity managers and educators on safety culture in health services, as well in program facilitation, these findings are important for future planning of maternity education programs across the state.Trial registrationTrial registration was not required for this study.

Determinants for the humanitarian workforce in migrant health at the US-Mexico border: optimizing learning from health professionals in Matamoros and Reynosa, Mexico.

Shortages of health professionals is a common problem in humanitarian settings, including among migrants and refugees at the US-Mexico border. We aimed to investigate determinants and recruitment recommendations for working with migrants to better understand how to improve health professional participation in humanitarian efforts. Semi-structured interviews were conducted with health professionals working with migrants at the US-Mexico border in Matamoros and Reynosa, Mexico. The study aimed to identify motivations, facilitators, barriers, and sacrifices to humanitarian work, and recommendations for effective learning approaches to increase participation. Participants included health professionals working within humanitarian organizations to deliver healthcare to migrants living in non-permanent encampments. Interviews lasted approximately 45 min and were analyzed in NVivo14 using a validated codebook and team-based methodology. Among 27 participants, most were female (70%) with median age 32. Health professionals included nurses (41%), physicians (30%), logisticians (11%), social workers (7%), an EMT (4%), and a pharmacist (4%) from the US (59%), Mexico (22%), Cuba (11%), Peru (4%), and Nicaragua (4%) working for four organizations. Participants expressed internal motivations for working with migrants, including a desire to help vulnerable populations (78%), past experiences in humanitarianism (59%), and the need to address human suffering (56%). External facilitators included geographic proximity (33%), employer flexibility (30%), and logistical support (26%). Benefits included improved clinical skills (63%), sociocultural learning (63%), and impact for others (58%). Negative determinants included sacrifices such as career obligations (44%), family commitments (41%), and safety risks (41%), and barriers of limited education (44%) and volunteer opportunities (37%). Participants criticized aspects of humanitarian assistance for lower quality care, feeling useless, and minimizing local capacity. Recommendations to increase the health workforce caring for migrants included integration of humanitarian training for health students (67%), collaborations between health institutions and humanitarian organizations (52%), and improved logistical and mental health support (41%). Health professionals from diverse roles and countries identified common determinants to humanitarian work with migrants. Recommendations for recruitment reflected feasible and collaborative approaches for professionals, organizations, and trainees to pursue humanitarian health. These findings can be helpful in designing interventions to address workforce shortages in humanitarian migrant contexts.

The impact of imperfect financial markets and stock holdings on corporate innovation: Evidence from China

According to previous research on developed countries, companies engaged in more corporate innovation are likely to have larger stock holdings. Companies are more likely to reserve stock holdings in a transitioning economy like China due to the prevalence of financial market flaws. This research suggests stock ownership and banking ties to the government as two alternative credit financing channels that Listed Chinese companies may employ to mitigate the effects of market imperfections by attracting foreign investment. Financial limitations can be efficiently mitigated through external finance facilitation channels (EFFCs) by lowering debtors and businesses have different levels of knowledge. However, the EFFC effect is diminishing due to the improved market environment brought about by China's ongoing financial reform. This research, therefore, considers potential avenues for reducing the EFFC effect, with practical policy implications for reforming China's financial markets to lower corporate innovation costs.

Facilitating the learning and adaptation process of regional initiatives that transform towards health and wellbeing systems.

Introduction: Health-systems in western countries are under pressure due to increasing costs, changing health care demands, and a growing shortage of staff. Therefore, regional initiatives are searching for ways to integrate and reorganize services across domains. This is a complex process and requires an incremental approach based on reflection and adaptation. However, regional initiatives are still searching how to construct these processes. This study aimed to gain more understanding of how the reflection and adaptation process in regional initiatives could be facilitated.
 Methods and analysis: This study included an action research within a Dutch regional initiative, including the program managers, involved municipalities, province, health care insurer and the public health services. The partners reflected on transformation themes, identified in previous evaluation studies, by scoring them in questionnaires and discussing them in interviews. Finally, two reflection meetings were facilitated with representation of all partners, respectively on management and board level. The program manager was interviewed about the experiences with this action research. Notes of this interview and observations of the reflection sessions were analyzed inductively. To broaden the experiences within this one initiative, the experiences with the reflection process were reflected upon in semi-structured interviews with program managers from other regional initiatives (n = 11). The semi-structured interviews were coded and clustered inductively.
 Results: Based on the scoring in questionnaires and interviews a radar chart was shown in the reflection meetings. This highlighted that especially two themes (accountability and citizen participation) would need adaptation. Partners especially recognized the problems regarding accountability and agreed that further elaboration was needed. One of the aims of the reflection process was to create a collective feeling of ownership. Results show that external facilitation of the reflection process, which was objective and knowledge-based, helped to enhance the collective conversation. Reflecting with the program managers of the other initiatives learned that not all initiatives invested in a regional reflection and adaptation process. Lack of this investment was related to partners not prioritizing this process. Some program managers expected the knowledge-based reflection to be helpful in creating a common ground among the partners. The use of scoring, like in the questionnaires, or having actionable options after scoring the themes was expected to be helpful to be able to act upon the reflection.
 Lessons learned and next steps: This study described the experiences with facilitating reflection and adaptation processes of regional initiatives. It showed that knowledge-based reflection by an external facilitator was valued to enhance the collective conversation and common ground about transformation. Further research is needed to learn how this common ground could eventually result in adaptation of the initiatives and thus aid their transformation. This research identified the importance of creating a collective process amongst partners for learning and adaptation, though found that not all initiatives invested in this process due to other priorities. More awareness among partners of the initiatives is needed about the importance of this process for transformation and their role in this collective process.
 

Face Ourselves: Striving for Antiracism in a Non-Profit

Advancing racial equity in workplaces requires ongoing and structural change. Organizations invested in this work need to view equity not as a checkbox, but as a continuous process of examination and change to organizational culture (Winters, 2020). In 2014, The Leadership Academy, a national education non-profit, began their journey to becoming an antiracist workplace. Through participatory action research methods, we focused on dismantling inequities and building empowerment, being iterative, and spurring staff’s greater awareness and action. Our journey has been undergirded by core elements of participatory research. We anchored ourselves in a commitment to supporting varying interests, perspectives, and styles of communication and participation. Here, we share what we produced and the practices we used, supported by lessons learned across our journey. We changed strategic plans, policies, and guiding values to be overtly antiracist, and we did so by supporting the voices and experiences of staff of color and spurring more involvement and accountability among white staff. These practices included affinity spaces, balancing small workgroups with whole-group discussions, and asynchronous work options. External facilitators were instrumental in helping us disrupt the structures and processes embedded in our organization; they held a mirror so we would truly face ourselves. We learned critical lessons about transparency, change management, flexibility, and relationships. Our antiracism journey at The Leadership Academy will never be done. Our dedicated, participant-led efforts yielded substantial shifts. We are eager to continue learning and pursuing deeper antiracist practices.