Internal Facilitators Research Articles

Integrating experiential learning into online facilitation at the National Open University of Nigeria

ABSTRACT This paper underscores the significance of experiential learning, emphasising active engagement and practical application, particularly in the realm of online education. This research is focused on the National Open University of Nigeria (NOUN). The study employs a survey research design involving internal and external online facilitators. The research explores the perceptions, benefits, challenges, and potential strategies for integrating experiential learning into online facilitation. With a sample size of 276, data collection utilised a structured questionnaire, and analysis involved descriptive and inferential statistics. The study’s findings have practical implications, informing policy decisions, instructional design practices, and faculty development initiatives at NOUN, ultimately aiming to enhance the holistic and immersive learning experience for online learners. The conclusion emphasises the potential of integrating experiential learning to elevate the quality, effectiveness, and real-world preparedness of NOUN’s online programmes, fostering student engagement and critical thinking.

DIABEZE: Diabetes self-management among the elderly in a Belgian home for the aged: a best practice implementation project.

The aim of this project was to improve the self-management of diabetes among elderly residents in a Belgian home for the aged. Diabetes is a common chronic condition with significant comorbidity. Incidence is increasing, but a third of patients with diabetes are unaware that they have the disease. The treatment of diabetes requires a multifactorial approach. Treatment guidelines on diabetes recommend involving patients in monitoring their condition because supported self-management improves daily glycemic control. This evidence implementation project used the JBI Evidence Implementation Framework, which follows three phases. In the first phase, the area of change, stakeholders' role, and practice context and readiness for change are investigated. In the second phase, a baseline audit is conducted to compare current practice with best practice. Strategies are then implemented to address any areas of non-compliance with best practice. In the third phase, a follow-up audit is conducted to evaluate changes in practice. At baseline, six criteria had 0% compliance, two criteria had compliance lower than 50%, and only 49% of health care workers were familiar with the procedure for hypoglycemia treatment. Improvement strategies included creating awareness among health workers. In the follow-up audit, one criterion improved from 0% to 100%, three criteria improved from 0% to 85%, two criteria reached the threshold of 50% compliance, and one criterion reached 19%. Further audits are needed to ensure sustainability. This project improved diabetes self-management in elderly people living in a Belgian home for the aged. An in-depth planning phase with internal facilitation and interdisciplinary collaboration between all co-workers addressed barriers related to quality systems, structure, communication, and education. http://links.lww.com/IJEBH/A258.

Factors associated with successful FLOW implementation to improve mental health access: a mixed-methods study.

The FLOW program assists mental health providers in transitioning recovered and stabilized specialty mental health (SMH) patients to primary care to increase access to SMH care. In a recent cluster-randomized stepped-wedge trial, nine VA sites implemented the FLOW program with wide variation in implementation success. The goal of this study is to identify site-level factors associated with successful implementation of the FLOW program, guided by the Consolidated Framework for Implementation Research (CFIR). We used the Matrixed Multiple Case Study method, a mixed-methods approach, to compare key metrics hypothesized to impact implementation that were aligned with CFIR. Based upon the number of veterans transitioned at each site, we categorized two sites as higher implementation success, three as medium, and four as lower implementation success. Themes associated with more successful implementation included perceptions of the intervention itself (CFIR domain Innovation), having a culture of recovery-oriented care and prioritizing implementation over competing demands (CFIR domain Inner Setting), had lower mental health provider turnover, and had an internal facilitator who was well-positioned for FLOW implementation, such as having a leadership role or connections across several clinics (CFIR domain Characteristics of Individuals). Other variables, including staffing levels, leadership support, and organizational readiness to change did not have a consistent relationship to implementation success. These data may assist in identifying sites that are likely to need additional implementation support to succeed at implementing FLOW.

Implementation of a rural emergency department-initiated buprenorphine program in the mountain west: a study protocol

BackgroundOpioid related overdose morbidity and mortality continue to significantly impact rural communities. Nationwide, emergency departments (EDs) have seen an increase in opioid use disorder (OUD)-related visits compared to other substance use disorders (SUD). ED-initiated buprenorphine is associated with increased treatment engagement at 30 days. However, few studies assess rural ED-initiated buprenorphine implementation, which has unique implementation barriers. This protocol outlines the rationale and methods of a rural ED-initiated buprenorphine program implementation study.MethodsThis is a two-year longitudinal implementation design with repeated qualitative and quantitative measures of an ED-initiated buprenorphine program in the rural Mountain West. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework outlines intervention assessments. The primary outcome is implementation measured by ED-initiated buprenorphine protocol core components. Reach, adoption, and maintenance are secondary outcomes. External facilitators from an academic institution with addiction medicine and prior program implementation expertise partnered with community hospital internal facilitators to form an implementation team. External facilitators provide ongoing support, recommendations, education, and academic detailing. The implementation team designed and implemented the rural ED-initiated buprenorphine program. The program includes OUD screening, low-threshold buprenorphine initiation, naloxone distribution and administration training, and patient navigator incorporation to provide warm hand off referrals for outpatient OUD management. To address rural based implementation barriers, we organized implementation strategies based on Expert Recommendations for Implementing Change (ERIC). Implementation strategies include ED workflow redesign, local needs assessments, ED staff education, hospital leadership and clinical champion involvement, as well as patient and community resources engagement.DiscussionMost ED-initiated buprenorphine implementation studies have been conducted in urban settings, with few involving rural areas and none have been done in the rural Mountain West. Rural EDs face unique barriers, but tailored implementation strategies with external facilitation support may help address these. This protocol could help identify effective rural ED-initiated buprenorphine implementation strategies to integrate more accessible OUD treatment within rural communities to prevent further morbidity and mortality.Trial RegistrationClinicalTrials.gov National Clinical Trials, NCT06087991. Registered 11 October 2023 – Retrospectively registered, https://clinicaltrials.gov/study/NCT06087991.

An external facilitation case study analysis of an implementation trial of FLOW: A program for improving the transition of patients with mental health disorders back to primary care.

FLOW (not an acronym) is a program that aims to improve mental health (MH) access using an algorithm that extracts electronic medical record data to identify recovered or stabilized MH patients who may be eligible to transition to primary care. The purpose of this case study was to describe and understand the factors that contributed to success or struggles in implementing FLOW. We conducted a posthoc evaluation of four health care sites implementing FLOW, using a mixed-method formal case study analysis. Qualitative data included written process notes, teleconference minutes, and interviews with internal facilitators (IF), MH providers, and patients who were transitioned. The external facilitation team also examined the degree to which IF characteristics matched suggested criteria. Quantitative data included discharge percentages and the percentage of providers who transitioned ≥ three patients during implementation. Sites were considered successful if they: (a) discharged ≥ 3% of their unique MH patients and (b) had a preponderance of patients who were satisfied with their MH to primary care transition. This article discusses two successful and two struggling FLOW sites based on these and other criteria and the factors that contributed to these outcomes. These case study findings increased understanding of how to successfully implement FLOW. The importance of shared decision making, selection of the IF, role definition, as well as leadership and organizational support are key elements in fostering appropriate transitions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Practice-Based Implementation Network: Behavioral Health Technician Optimization Pilot Lessons Learned.

Between June 2021 and December 2022, the Practice-Based Implementation (PBI) Network conducted a pilot to study the optimization of behavioral health technicians (BHTs) within military behavioral health (BH) care system specialty BH clinics. Behavioral health technicians are paraprofessionals found in all branches of the military, and with training across a variety of clinic functions. Behavioral health technicians support BH specialty providers in many clinic functions (i.e., administrative, case management, clinical, and outreach). The primary aim of the BHT optimization pilot was to increase BHTs' involvement in clinical care. Four military BH outpatient clinics participated in the BHT optimization pilot. Participants from the 4 clinics included 12 BHTs, 3 providers, 3 internal facilitators, and 3 dual-role providers/internal facilitators. The pilot asked each clinic to assess their BHT utilization needs, and then barriers and facilitators to BHT optimization were addressed by creating site-specific BHT optimization plans. The degree to which clinic optimization of BHTs impacts provider workload, clinic capability or capacity, and patient access to evidence-based care could not be determined during the BHT optimization pilot. However, individualized clinic BHT optimization plans and strategies appeared to be feasible and acceptable methods for military health system BH clinics to optimize BHTs' clinical skills. Lessons learned from this pilot included that: (1) clinics should consider establishing and maintaining action plans with specific, actionable goals for use of BHTs, and (2) BHT supervision, training, and clinic processes supporting optimization should be prioritized despite time constraints. Overall, individualized clinic BHT optimization plans and strategies appear to be feasible and acceptable methods for military health system BH clinics to optimize BHTs' clinical skills.

Physical Activity Participation among Children and Youth with Mental Health Symptoms: Clinician Perspectives.

Physical activity supports mental health and well-being in children and youth. However, there are significant barriers to physical activity participation among individuals impacted by mental health disorders. This study investigates these barriers through the perspective of mental health clinicians who support children and youth. Fourteen mental health clinicians, including registered professional psychologists, psychotherapists, and social workers, were interviewed in a semi-structured format. Qualitative content analysis was performed to identify key themes, including both barriers and facilitators to physical activity. Content analysis revealed that clinicians perceive both internal and external barriers and facilitators to their clients' participation in physical activity. Barriers included intrapersonal factors, such as the presence of depression, anxiety, or eating disorder symptoms; lack of motivation; and negative self-talk, as well as factors related to the influence of caregivers, financial limitations, screen time use, environmental and cultural factors, and lack of time. Facilitators included enjoyment of physical activity, knowledge about the benefits of physical activity, and caregiver participation. Mental health clinicians demonstrated clear knowledge about the barriers to and facilitators of their clients' participation in physical activity. These findings provide valuable insights that can be used to support children and youth experiencing mental health difficulty to access the beneficial effects of physical activity.

Barriers and Facilitators to Administering Burn Pit Registry Exams in VHA Facilities.

The Veterans Health Administration (VHA) established the Airborne Hazards and Open Burn Pit Registry (AHOBPR) in 2014 to address exposure concerns for veterans who have served in military operations in Southwest Asia and Afghanistan. By 2021, over 236,086 veterans completed the online questionnaire and 60% requested an AHOBPR examination. Of those requesting an exam, only 12% had an exam recorded in their medical record. This article summarizes barriers and facilitators to delivering AHOBPR exams and shares lessons learned from facilities who have successfully implemented burn pit exams for veterans. We (I.C.C and J.H.) constructed a key performance measure of AHOBPR examination (the ratio of examinations performed in facility over examinations assigned to a facility) to identify top performing facilities and then used stratified purposeful sampling among high-performing sites to recruit a diverse set of facilities for participation. We (P.V.C. and A.A.) recruited and interviewed key personnel at these facilities about their process of administering burn pit exams. Rapid qualitative methods were used to analyze interviews. The ratio of exams performed to exams assigned ranged from 0.00 to 14.50 for the 129 facilities with available information. Twelve interviews were conducted with a total of 19 participants from 10 different facilities. We identified 3 barriers: Unclear responsibility, limited incentives and competing duties for personnel involved, and constrained resources. Facilitators included the presence of an internal facilitator, additional staff support, and coordination across a facility's departments to provide care. Gaps across many VHA facilities to provide AHOBPR exams may be understood as stemming from organizational issues related to clear delegation of responsibility and staffing issues. VHA facilities that wish to increase AHOBPR exams for veterans may need additional administrative and medical staff.

“Recovery activities are needed every step of the way”—exploring the process of long-term recovery in people previously diagnosed with exhaustion disorder

BackgroundSick-leave rates are high due to stress-related illnesses, but little is still known about the process of recovery from these conditions. The aim of this study was to explore the experiences of the recovery process, 6 to 10 years after treatment in people previously diagnosed with exhaustion disorder (ED), focusing on facilitators and barriers for the process of recovery from ED, and recovery activities experienced as helpful during the recovery process.MethodThirty-eight participants (average age: 52 years, 32 females) previously diagnosed with ED were interviewed with semi-structured interviews 6–10 years after undergoing treatment. The interviews were analyzed with thematic analysis.ResultsThree themes resulted from the analysis. The first theme, “A long and rocky road”, summarizes the fluctuating path to feeling better and emphasizes barriers and facilitators that affected the process of recovery, with a focus on external life events and the participants’ own behaviors. Facilitators were changing workplace, receiving support, a reduction in stressors, and changed behaviors. Barriers were a poor work environment, caregiver responsibilities, negative life events and lack of support. The second theme “Recovery activities are needed every step of the way” describes how both the need for recovery activities and the types of activities experienced as helpful changed during the recovery process, from low-effort recovery activities for long periods of time to shorter and more active recovery activities. Recovery activities were described as important for self-care but hard to prioritize in everyday life. The last theme, “Reorienting to a new place”, captures the struggle to cope with the remaining impact of ED, and how internal facilitators in terms of understanding and acceptance were important to reorient and adjust to a new way of functioning.ConclusionsRecovering from ED is a long and ongoing process where recovery activities are needed every step of the way. Our results highlight the importance of supporting personal recovery and long-term behavioral change, addressing individual stressors that may perpetuate the condition, and adjusting recovery activities according to where the person is in the recovery process.Trial registrationClinicalTrials.gov: NCT0073772. Registered on March 8, 2017. This study was pre-registered on Open Science Framework (osf.io).

Scientific Communication Initiative at a Medical Military Library

Implementation of new scholarly communication library service in the digital age is characterized by the competitive forces between the old library information services and the ambiguity of future information services. This research analyzes the development process of scientific initiative and collaborative partnership in the military medical library environment aimed to enhance the quality of scientific communication and information skills in military residents and clinicians. The hindering internal and external forces and facilitators of developing and implementing scientific initiative service in the military medical library are evaluated. The environmental analysis was conducted to determine the scholarly communication needs in the scholarly military medical environment. The ambassador-based model was used for the development of scientific communication initiative (SCI) at the military medical library. The SCI consisted of two components: library information communication and scientific communication. This implementation in the military medical environment enhanced scholarly communication, research skills development, and information education. A collaborative Scientific Hub, and liaison partnerships with military graduate medical education program directors and clinicians enhanced the scientific communication and information skills in residents. The Ambassador model, used in the development of scientific initiative in academic and military environments, was valuable for developing and implementing specialized interdisciplinary and multidisciplinary information services in the academic and military environment. Higher education hierarchy, educational needs, organizational hierarchy, academic culture, and educational environment influence the implementation of information services in academic and military environments.

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.

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.

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.

"The Only Reason I Am Willing to Do It at All": Evaluation of VA's SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center.

Medication treatment for opioid use disorder (MOUD) is effective and recommended for outpatient settings. We implemented and evaluated the SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center-a quality improvement partnership to implement stepped care for MOUD in 2 Veterans Health Administration (VA) primary care (PC) clinics. SUPPORT provided a dedicated clinical team (nurse practitioner prescriber and social worker) and stepped care ([1] identification, assessment, referral; [2] MOUD induction; [3] stabilization; and [4] maintenance supporting PC providers [PCPs] to initiate and/or sustain treatment) coupled with ongoing internal facilitation (consultation, trainings, informatics support). Qualitative interviews with stakeholders (PCPs and patients) and meeting notes identified barriers and facilitators to implementation. Electronic health record and patient tracking data measured reach, adoption, and implementation outcomes descriptively. SUPPORT's implementation barriers included the need for an X-waiver, VA's opioid tapering policies, patient and PCP knowledge gaps and PCP discomfort, and logistical compatibility and sustainability challenges for clinics. SUPPORT's dedicated clinical staff, ongoing internal facilitation, and high patient and PCP satisfaction were key facilitators. SUPPORT (January 2019 to September 2021) trained 218 providers; 63 received X-waivers, and 23 provided MOUD (10.5% of those trained). SUPPORT provided care to 167 patients, initiated MOUD for 33, and provided education and naloxone to 72 (all = 0 in year before launch). SUPPORT reached many PCPs and patients and resulted in small increases in MOUD prescribing and high levels of stakeholder satisfaction. Dedicated clinical staff was key to observed successes. Although resource-intensive, SUPPORT offers a potential model for outpatient MOUD provision.

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.

Exploring the Meanings of Posttraumatic Growth in Spanish Survivors of Clergy-Perpetrated Child Sexual Abuse: A Phenomenological Approach

ABSTRACT A healing and recovery perspective related to child sexual abuse (CSA) has gained attention in the past two decades, a concept that accurately refers to the process is posttraumatic growth (PTG). Scarce empirical research on PTG in clergy-perpetrated CSA survivors shows evidence of the presence of growth after the abusive experience and a tendency to create accounts of trauma as a way to heal. The general aim of the study is to explore the experiences and meanings of PTG as lived by survivors of clergy-perpetrated CSA. Seven clergy-perpetrated CSA survivors were interviewed with semi-structured in-depth interviews conducted in person. Using reflexive thematic analysis, we identified three dominant themes in the participants’ stories: (a) the hindering of PTG; (b) the meanings of PTG, and (c) the internal and contextual and facilitators of PTG. The present study brings new insights into the meanings of PTG, the close relationship between damage and growth, and the mechanisms (both internal and contextual) that are involved in healing from clergy-perpetrated CSA in Spanish culture.

Exploring expectations and readiness for healthy lifestyle promotion in Swedish primary health care: a qualitative analysis of managers, facilitators, and professionals

Objective Prior to a multifaceted implementation strategy for a healthy lifestyle-promoting practice the expectations of primary health care managers, appointed internal facilitators and health care professionals on supporting change was explored. Design This study had an explorative qualitative design using data gathered from individual interviews and focus groups. Qualitative content analysis with a deductive category development was applied using the Consolidated Framework for Implementation Research. Setting and participants The study was conducted in a primary care setting in central Sweden as a part of the Act in Time research project. Prior to a multifaceted implementation strategy, we held 16 individual interviews with managers and appointed facilitators and five focus groups with 26 health care professionals. Results Managers, facilitators, and professionals held similar expectations, where their expressed need for support corresponded to three constructs: Readiness for implementation, Implementation climate, and Engaging. Our findings indicate the need for strong leadership engagement to focus on how the healthy lifestyle-promoting practice can be anchored among the professionals. Managers at all levels should communicate the vision and goals, enable facilitators and professionals to improve their competencies, build inter-professional teams, and jointly plan the new practice. Conclusion To change to a healthy lifestyle promoting practice professionals request support from their managers, who in turn need support from the middle and top managers. The requested support includes helping to prioritise health promotion and enabling the primary care centres to build competence and take ownership of the implementation. Trial registration ClinicalTrials.gov NCT04799860

Adaptation for sustainability in an implementation trial of team-based collaborative care.

Sustaining healthcare interventions once they have been implemented is a pivotal public health endeavor. Achieving sustainability requires context-sensitive adaptations to evidence-based practices (EBPs) or the implementation strategies used to ensure their adoption. For replicability of adaptations beyond the specific setting in question, the underlying logic needs to be clearly described, and adaptations themselves need to be plainly documented. The goal of this project was to describe the process by which implementation facilitation was adapted to improve the uptake of clinical care practices that are consistent with the collaborative chronic care model (CCM). Quantitative and qualitative data from a prior implementation trial found that CCM-consistent care practices were not fully sustained within outpatient general mental health teams that had received 1 year of implementation facilitation to support uptake. We undertook a multistep consensus process to identify adaptations to implementation facilitation based on these results, with the goal of enhancing the sustainability of CCM-based care in a subsequent trial. The logic for these adaptations, and the resulting adaptations themselves, were documented using two adaptation-oriented implementation frameworks (the iterative decision-making for evaluation of adaptations [IDEA] and the framework for reporting adaptations and modifications to evidence-based implementation strategies [FRAME-IS], respectively). Three adaptations emerged from this process and were documented using the FRAME-IS: (a) increasing the scope of implementation facilitation within the medical center, (b) having the internal facilitator take a greater role in the implementation process, and (c) shortening the implementation timeframe from 12 to 8 months, while increasing the intensity of facilitation support during that time. EBP sustainability may require careful adaptation of EBPs or the implementation strategies used to get them into routine practice. Recently developed frameworks such as the IDEA and FRAME-IS may be used to guide decision-making and document resulting adaptations themselves. An ongoing funded study is investigating the utility of the resulting adaptations for improving healthcare.

Improving self-management for diabetes in a Flemish nursing home: An implementation project using the JBI Implementation Framework

The number of people with type 2 diabetes is increasing, both in our country and internationally. Accurate monitoring is very important. After all, accurate monitoring of blood values can prevent long-term problems such as chronic wounds or eye disease. Involving the patient in monitoring this condition is also recommended by treatment guidelines. Supported self-management improves daily glycemic control. Zorgbedrijf Antwerp, an organisation with home care services, nursing homes and units for assited-living, was looking for good ways to encourage this self-management among caregivers. Both in their home care services and in the residential care centers, Zorgbedrijf experienced insufficient involvement with the elderly to take control of their disease process. Among staff, they notice insufficient attention to education and empowerment for their residents with diabetes.
 Several interventions are suggested from the literature to promote self-management in older people with type 2 diabetes. A 2017 systematic review concludes that effective self-management interventions use communication, data provided by the patient, education and feedback.
 To put these interventions into practice, several implementation models are available.
 The JBI Evidence Implementation Framework (EIF) devotes explicit attention to the methodical application of new up-to-date evidence and, in addition to a step-by-step plan for determining readiness, offers guidance in determining indicators. This ensures sustainable implementation. More than a theoretical framework, this model also includes practical tools for the search for the best available evidence, the interventions to be implemented and the criteria to measure effect. In Belgium, this model has never been used before, but numerous successful projects are available abroad. With funding of Ebpracticenet, a pilot project was set up- to implement self management for diabetes in one nursing home from Zorgbedrijf, using the JBI EIF, guided by the Belgian Interuniversity Collaboration for Evidence-based Practice (BICEP). Important in the Framework is the use of an internal facilitator. First, this internal facilitator was trained by Bicep to search for evidence and how to use audit and feedback in implementation projects. Clinical leadership is taught to support equity in the stakeholders. In a second phase a multidisciplinary working group was established with all relevant stakeholders. This group was given the mandate to set up criteria and methods for implementation. In this way, clinical engagement is taken into account. Eight criteria were chosen from an evidence summary provided by the JBI database. An in depth context analysis looked revealed additional barriers in structure, culture, communication, resources, leadership, knowledge or attitudes. At present, baseline measurement is finished. Together with the working group, an action plan has been formulated and the kickoff meeting is planned. What we can see already is a project that is driven by a whole team, bottom up. From December to March 2023 , the self-management will start for all eligible new residents. At the ICIC conference, the follow up measurement will show us all relevant results and give us the data for a sustainable follow up of the project.

Using the Matrixed Multiple Case Study approach to identify factors affecting the uptake of IPV screening programs following the use of implementation facilitation

BackgroundIntimate partner violence (IPV) is a prevalent social determinant of health. The US Preventive Services Task Force recommends routine IPV screening of women, but uptake remains variable. The Veterans Health Administration (VHA) initiated implementation facilitation (IF) to support integration of IPV screening programs into primary care clinics. An evaluation of IF efforts showed variability in IPV screening rates across sites. The follow-up study presented here used a Matrixed Multiple Case Study (MMCS) approach to examine the multilevel factors impacting IPV screening program implementation across sites with varying levels of implementation success.MethodsThis mixed methods study is part of a larger cluster randomized stepped wedge Hybrid-II program evaluation. In the larger trial, participating sites received 6 months of IF consisting of an external facilitator from VHA’s Office of Women’s Health working closely with an internal facilitator and key site personnel. Recognizing the heterogeneity in implementation outcomes across sites, the MMCS approach was used to enable interpretation of qualitative and quantitative data within and across sites to help contextualize the primary findings from the larger study. Qualitative data collection was guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and included interviews with key informants involved in IPV screening implementation at eight sites. Quantitative data on IPV screening uptake was derived from medical records and surveys completed by key personnel at the same eight sites to understand implementation facilitation activities.ResultsFifteen factors influencing IPV screening implementation spanning all four i-PARIHS domains were identified and categorized into three distinct categories: (1) factors with enabling influence across all sites, (2) factors deemed important to implementation success, and (3) factors differentiating sites with high/medium versus low implementation success.ConclusionsUnderstanding the influencing factors across multi-level domains contributing to variable success of IPV screening implementation can inform the tailoring of IF efforts to promote spread and quality of screening. Implementation of IPV screening programs in primary care with IF should consider consistent engagement of internal facilitators with clinic staff involved in implementation, the resourcefulness of external facilitators, and appending resources to IPV screening tools to help key personnel address positive screens.Trial registrationClinicalTrials.gov NCT04106193. Registered on September 26, 2019.