Practice Facilitation Research Articles

Practice facilitation to implement alcohol-related care in Veterans Health Administration liver clinics: a study protocol

BackgroundAlcohol-related care, including screening, brief intervention, and provision of/referral to medication or behavioral treatments for alcohol use disorder, could be delivered in liver clinics to better reach patients with chronic liver conditions. However, the provision of alcohol-related care in liver clinics is currently suboptimal. Practice facilitation is an evidence-based implementation strategy that may address barriers, harness facilitators, and optimize the implementation of alcohol-related care in liver clinic settings using a clinic-centered approach. We report the protocol of a study to test a practice facilitation intervention to implement alcohol-related care in four Veterans Health Administration liver clinics.MethodsThis study will employ a Hybrid Type 3 effectiveness-implementation design, in which implementation outcomes are considered primary and clinical outcomes secondary. Intervention and evaluation design were informed by the Consolidated Framework for Implementation Research. Qualitative data collected from clinical stakeholders and patients were used to tailor the intervention. The intervention involves a 6-month period of external practice facilitation, including regular meetings to identify clinic goals, challenges, and solutions; engagement of clinic champions; provision of training and development of educational materials for clinic staff and patients; and performance monitoring and feedback. Ongoing formative evaluation involves the collection of quantitative facilitator tracking data and qualitative data from meeting notes and patient interviews to describe intervention acceptability, feasibility, and adoption, and adjust implementation as needed. In the summative evaluation, implementation outcomes (clinic rates of screening, brief intervention, and treatment referral/receipt) and clinical outcomes (unhealthy alcohol use, liver health) will be assessed among patients in participating clinics using secondary electronic health record data and interrupted time series analysis.DiscussionThis will be the first study to our knowledge to test practice facilitation to implement alcohol-related care in liver clinic settings. Results from formative and summative evaluation will inform a framework for the successful implementation of effective alcohol-related care through practice facilitation in liver clinics, which may ultimately lead to better health outcomes for patients with chronic liver disease.

Retrieval practice facilitation of family psychoeducation in people with early psychosis

BackgroundProviding early psychosis (EP) individuals with family psychoeducation (FPE) can reduce symptoms and improve clinical outcomes. However, relational memory problems may limit prospective utilization of FPE information. This study examines whether memory for FPE can be improved by testing participants during the initial FPE workshop presentation. MethodData were obtained from 20 people with EP and 20 demographically matched healthy comparison subjects (HC). During session one, FPE was presented in small group workshops, with half of the information re-studied twice (re-study condition) and the remaining information tested twice using cued recall tasks (retrieval practice condition). One week later (session two), delayed cued recall was tested for all FPE information. “Testing effects” (i.e., better memory following retrieval practice versus re-study) were examined across all items (standard analysis) and also limited to items successfully retrieved during session one (conditionalized analysis). ResultsHC had better initial recall and learned more over the two retrieval practice trials than EP. However, HC also lost more information than EP over the one-week delay. Both groups produced a significant testing effect. This effect was smaller in EP versus HC across all test items, but did not differ for the conditionalized analysis. Negative symptoms were inversely correlated with delayed cued recall in EP. ConclusionsEP participants benefit from retrieval practice, with participants with less severe negative symptoms showing the greatest benefit. These results encourage use of memory tests during group psychoeducation to improve subsequent long-term recall of clinically relevant information.

Practice level factors associated with enhanced engagement with practice facilitators; findings from the heart health now study

BackgroundPractice facilitation is a promising strategy to enhance care processes and outcomes in primary care settings. It requires that practices and their facilitators engage as teams to drive improvement. In this analysis, we explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month practice facilitation intervention focused on implementing cardiovascular prevention activities in practice. Understanding factors associated with greater engagement with facilitators in practice-based quality improvement can assist practice facilitation programs with planning and resource allocation.MethodsOne hundred thirty-six ambulatory care small to medium sized primary care practices that participated in the EvidenceNow initiative’s NC Cooperative, named Heart Health Now (HHN), fit the eligibility criteria for this analysis. We explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month intervention using a retrospective cohort design that included baseline survey data, monthly practice activity implementation data and information about facilitator’s experience. Generalized linear mixed-effects models (GLMMs) identified variables associated with greater odds of team engagement using an ordinal scale for level of team engagement.ResultsAmong our practice cohort, over half were clinician-owned and 27% were Federally Qualified Health Centers. The mean number of clinicians was 4.9 (SD 4.2) and approximately 40% of practices were in Medically Underserved Areas (MUA). GLMMs identified a best fit model. The Model presented as odd ratios and 95% confidence intervals suggests greater odds ratios of higher team engagement with greater practice QI leadership 17.31 (5.24–57.19), [0.00], and practice location in a MUA 7.25 (1.8–29.20), [0.005]. No facilitator characteristics were independently associated with greater engagement.ConclusionsOur analysis provides information for practice facilitation stakeholders to consider when considering which practices may be more amendable to embracing facilitation services.

Dynamic waitlisted design for evaluating a randomized trial of evidence-based quality improvement of comprehensive women\u2019s health care implementation in low-performing VA facilities

BackgroundWomen’s Health Services (WHS) in the Veterans Health Administration (VA) has long partnered with VA researchers to evaluate how VA care is organized for women veterans. This partnership has yielded substantial evidence of (1) variations in women veterans’ access to comprehensive healthcare services that contribute to disparities in quality and patient experience and (2) the positive impacts of gender-specific care models for women veterans’ quality and satisfaction. In an effort to provide support specifically to sites that were low-performing in women’s health, WHS and the VA Quality Enhancement Research Initiative co-funded an effort to roll out and evaluate evidence-based quality improvement (EBQI), an implementation strategy with demonstrated effectiveness in a prior cluster randomized trial in women’s health clinics.MethodsWe will identify 21 low-performing VA facilities through a combination of practice data, VA quality metrics (by gender), and other indicators. In partnership with WHS, an EBQI contractor will deliver the EBQI “package”—local consensus development and priority setting using stakeholder panels, multilevel stakeholder engagement, practice facilitation, local EBQI team training, and formative feedback—to participating sites. We propose a dynamic wait-listed design to evaluate the WHS plans for seven EBQI launches per year over 3 years. The goal is to evaluate (1) barriers and facilitators to achieving delivery of comprehensive women’s health care in low-performing VA facilities; (2) effectiveness of EBQI in supporting low-performing VA facilities to achieve improved practice features (e.g., level of comprehensive services available, care coordination arrangements, Patient Aligned Care Team (PACT) features implemented, environment of care improvements), provider/staff attitudes (e.g., improved gender awareness, women’s health knowledge and practice), quality of care, and patient experience; and (3) contextual factors, local implementation processes, and organizational changes over time.DiscussionAccess to comprehensive women’s health care reduces fragmentation of care, improves patient satisfaction, and results in better patient outcomes. We hypothesize that EBQI implementation will result in changes in leadership awareness and buy-in, multilevel engagement in problem-solving, an enhanced culture of quality improvement, structural changes in care, improved provider/staff attitudes, and better quality and patient experience.Trial registrationClinicalTrials.gov, NCT03238417. Registered 3 August 2017. Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT03238417

Supporting Australian clinical learners in a collaborative clusters education model: a mixed methods study

BackgroundNursing student numbers have risen in response to projected registered nurse shortfalls, increasing numbers of new graduates requiring transitional support and pressure on clinical placements. A Collaborative Clusters Education Model, in which Entry to Practice facilitators coach ward-based registered nurses to support students’ and new graduates’ learning, may address placement capacity. The research aim was to evaluate the acceptability of the Collaborative Clusters Education Model to stakeholders by examining their perceptions of the facilitators and barriers to the model in its implementation.MethodsA convergent mixed methods evaluation approach was adopted. The study took place in a large Australian health service in south-east Queensland. Participants included Bachelor of Nursing students, Entry to Practice facilitators, ward-based registered nurses, academics and new graduates. A mixed methods design was used. Elements included an online survey of nursing students, and interviews with new graduates, Entry to Practice facilitators, ward-based registered nurses, and academics. Descriptive statistics were calculated on quantitative data. Thematic analysis was conducted on qualitative data.ResultsParticipants included 134 (of 990) nursing students (response rate 13.5%), five new graduates, seven Entry to Practice facilitators, four registered nurses, and three nurse academics. Students rated facilitators’ effectiveness highly (4.43/5 ± 0.75), although this finding is tempered by a low response rate (13.5%). For learners, the model provided access to learning experiences, although preferences for sources of support differed between students and new graduates, and further clarification of responsibilities was required. For other stakeholders, three themes emerged: students’ and new graduates’ integration into the workplace can promote learning; tensions arise in new ways to approach performance assessment; and aligning expectations requires high levels of communication.ConclusionsThis evaluation found that acceptability was good but at risk from limited clarity around roles and responsibilities. Further research into this model is recommended.

Interactive workshop to develop implementation framework (i-PARIHS) resources to support practice facilitation

BackgroundPractice facilitation is a method used to address the complexity associated with implementation of innovations into primary care. To provide support, we propose that the i-PARIHS (Integrated Promoting Action on Research Implementation in Health Services) framework could support practice facilitators. The i-PARIHS framework positions facilitation as a core element for successful implementation. Therefore, the aim of this study was to provide support to practice facilitators whilst simultaneously gaining feedback on what facilitators in practice need in regard to support with operationalising the i-PARIHS framework in practice.MethodsThis study involved the delivery of a 1-h workshop on the i-PARIHS framework at the 2018 International Conference on Practice Facilitation. The authors provided an overview of the i-PARIHS framework, how it can be used to support the facilitation of innovations into practice, and finally, attendees worked through facilitation scenarios and applied an i-PARIHS resource. At the end of the workshop, attendees were invited to participant in the research component, by completing a post-workshop survey on the workshop content and the i-PARIHS resource.ResultsParticipants were highly engaged and enthusiastic about the workshop. Participants reported that an introduction to implementation frameworks was valuable and the example of how the i-PARIHS framework had been used in a previous project was helpful. Overall, this study identifies how framework informed facilitation helped participants feel more equipped to conduct systematic facilitation and that the development of i-PARIHS resources would be helpful in their everyday work.ConclusionsThis study demonstrates that the existence of implementation frameworks is not sufficient to provide support to those who facilitate in the real world. The current study introduced practice facilitators to the i-PARIHS framework, and the findings demonstrate the need to develop and refine existing i-PARIHS resources to support facilitation. Specifically, the next steps stemming from this study will be to (i) continue to utilize workshops for sharing and refining tools, (ii) allocate development efforts to tools that assist with planning, (iii) focus on tool provision mechanisms that keep user-friendliness in mind, and (iv) translate the i-PARIHS facilitation checklist from academic language into more practical and user-friendly language.

The Evolution of a Clown in Service: Reflections on Therapeutic Clowning in Canada

Drawing on their experience as therapeutic clown practitioners, reflective practice facilitators, and trainers, the authors reflect thoughtfully on three key questions: What is the deeper nature of this relational practice called therapeutic clowning? Why are seasoned professional performers increasingly being drawn to this practice? What kinds of adaptations and considerations does a clown artist undertake to move from the world of theatre and performance to the world of health care and compassionate service? Beginning with a brief look at the evolution of therapeutic clowning in Canada and abroad, the authors turn to a deeper consideration of practices in pediatric, adult, and dementia-care settings. Child life and clown doctor pediatric models of therapeutic clown are delineated, as is the Elder-clown approach used by many practitioners working with older people in long-term care and community care. The authors emphasize the importance of reciprocity and co-created play between practitioner(s) and the people they serve and consider the role these play in bolstering resilience, vitality, and a sense of agency in the lives of vulnerable people in hospital and institutionalized care settings. The article also emphasizes that foundational clown training and performance experience alongside specialized training are crucial for therapeutic clown practitioners. Throughout, poignant vignettes illustrate and illuminate the complex, challenging, and rewarding dimensions of therapeutic clown practice.

Practice Facilitation in Integrated Behavioral Health and Primary Care Settings: a Scoping Review.

Little is known about the contributions of practice facilitators in settings aiming to deliver integrated behavioral health and primary care. This scoping review identifies peer-reviewed articles that describe efforts to deliver integrated behavioral health care with the support of practice facilitators. Five databases were systematically searched to identify empirical and conceptual papers. Fourteen articles met the following inclusion criteria: (1) empirical studies evaluating the effectiveness of practice facilitation (n = 4), (2) study protocols that will test the effectiveness of practice facilitation (n = 2), (3) studies that included practice facilitators as part of a larger intervention without evaluating their effectiveness (n = 5), and (4) conceptual manuscripts endorsing practice facilitation for integrated care (n = 3). Practice facilitators can potentially support health systems in delivering integrated behavioral health care, but future research is needed to understand their necessary qualifications, the effectiveness of practice facilitation these efforts, and what study outcomes are appropriate for evaluating whether practice facilitation has been effective.

Practice facilitation to promote evidence-based screening and management of unhealthy alcohol use in primary care: a practice-level randomized controlled trial

BackgroundUnhealthy alcohol use is the third leading cause of preventable death in the United States. Evidence demonstrates that screening for unhealthy alcohol use and providing persons engaged in risky drinking with brief behavioral and counseling interventions improves health outcomes, collectively termed screening and brief interventions. Medication assisted therapy (MAT) is another effective method for treatment of moderate or severe alcohol use disorder. Yet, primary care clinicians are not regularly screening for or treating unhealthy alcohol use.Methods and analysisWe are initiating a clinic-level randomized controlled trial aimed to evaluate how primary care clinicians can impact unhealthy alcohol use through screening, counseling, and MAT. One hundred and 25 primary care practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) will be engaged; each will receive practice facilitation to promote screening, counseling, and MAT either at the beginning of the trial or at a 6-month control period start date. For each practice, the intervention includes provision of a practice facilitator, learning collaboratives with three practice champions, and clinic-wide information sessions. Clinics will be enrolled for 6–12 months. After completion of the intervention, we will conduct a mixed methods analysis to identify changes in screening rates, increase in provision of brief counseling and interventions as well as MAT, and the reduction of alcohol intake for patients after practices receive practice facilitation.DiscussionThis study offers a systematic process for dissemination and implementation of the evidence-based practice of screening, counseling, and treatment for unhealthy alcohol use. Practices will be asked to implement a process for screening, counseling, and treatment based on their practice characteristics, patient population, and workflow. We propose practice facilitation as a robust and feasible intervention to assist in making changes within the practice. We believe that the process can be replicated and used in a broad range of clinical settings; we anticipate this will be supported by our evaluation of this approach.Trial registrationClinicalTrials.gov, ClinicalTrials.gov Identifier: NCT04248023, Registered 5 February 2020.

Research nurses as practice facilitators to disseminate an asthma shared decision making intervention

BackgroundPractice facilitation is a method of introducing and sustaining organizational change. It involves the use of skilled healthcare professionals called practice facilitators (PFs) to help address the challenges associated with implementing evidence-based guidelines and complex interventions into practice. PFs provide a framework for translating research into practice by building relationships, improving communication, fostering change, and sharing resources. Nurses are well positioned to serve as PFs for the implementation of complex interventions, however, there is little evidence currently available to describe nurses in this role. Additionally, the best strategies to implement complex interventions into practices are still not fully understood. Combining practice facilitation with the train-the-trainer model has the potential to spread knowledge and skills. Shared decision making (SDM), which involves patients and providers jointly engaging in decisions around treatment options, has been shown to improve outcomes for patients with asthma. The goal of this manuscript is to describe and evaluate the practice facilitation process from the ADAPT-NC Study which successfully utilized research nurses to implement a complex asthma SDM toolkit intervention into primary care practices.MethodsAs part of a larger study, 10 primary care practices were recruited for a facilitator-led dissemination intervention involving a 12-week rollout of an asthma SDM toolkit (trial registration: 1.28.2014, #NCT02047929). An experienced lead PF trained research nurses as PFs from each of the 4 participating practice-based research networks (PBRNs) in a train-the-trainer model utilizing a one-day training event and subsequent remote meetings. Evaluation of PF engagement was measured through process improvement surveys.ResultsOverall, the asthma SDM intervention was successfully implemented within the 4 PBRNs. All 10 facilitator-led practices remained engaged with their PFs, with 8 out of the 10 practices able to incorporate and sustain SDM visits or clinics. Responses from the surveys for process improvement yielded improved PF communication and team dynamics over time.ConclusionsThis study demonstrated effective use of research nurses as practice facilitators during the dissemination of an asthma SDM intervention into primary care practices, adding to the knowledge of best practices by describing a model of large-scale implementation of a complex intervention through practice facilitation with nurses.Trial registration“Comparing Traditional and Participatory Dissemination of a Shared Decision Making Intervention” was retrospectively registered at https://clinicaltrials.gov/ on January 28th, 2014 (NCT02047929).

Implementing Evidence-Based Practice Facilitators: A Case Series.

In 2017, the TriService Nursing Research Program completed a strategic planning session, which identified key barriers to implementing evidence-based practice (EBP) within the U.S. Military Health System (MHS) including a focus on readiness training and deployments, frequent staff moves for military members, and relatively junior nurses in clinical roles. To facilitate EBP at individual military treatment facilities (MTFs), an EPB Facilitator role was developed using an evidence-based model and based on validated EBP competencies. This new role was implemented at four MTFs in 2018: Naval Medical Center Portsmouth, 59th Medical Wing at Joint Base San Antonio Lackland, Naval Medical Center San Diego, and David Grant USAF Medical Center at Travis Air Force Base. This case series provides a description of the initial implementation of this role. Common enablers and challenges were identified from the experiences at all four sites. These included the importance of incorporating efforts into existing organizational efforts and infrastructure; the value of nurse leaders inviting EBP facilitators to participate and engage in scheduled meetings and committees; the significance of engaging with existing quality, process improvement, and training initiatives; and the benefit of collaborating with advanced practice nurses within the organization. The common challenges for all EBP facilitators were the frequent staff turnover at all levels and a lack of standardization to review and approve EBP initiatives, which makes it difficult to navigate the complete process of project implementation and collaboration across sites. Another challenge has been the difficulty to measure the impact of this role at the MTF and MHS levels. As EBP efforts continue and the program matures, it is anticipated that the outcomes from the individually completed projects, to include decreases in safety events, fiscal savings, and other improvements in organizational metrics, can be compiled to demonstrate the collective impact of these roles within the MHS.

Contrasting Perspectives of Practice Leaders and Practice Facilitators May Be Common in Quality Improvement Initiatives.

Practice facilitation is an approach for advancing quality improvement (QI), but its success depends on effective relationships and communication among participants. Our goal was to identify patterns of contrasting perspectives on implementation issues between practice leaders and their practice facilitators, and factors that may contribute to them. We conducted individual interviews with practice leaders and the practice facilitators assigned to them as part of a program focused on preventive cardiology within primary care practices. We used summative content analysis to quantify the incidence of contrasting perspectives, and bivariate and qualitative analyses to explore relationships between contrasting perspectives and contextual factors. Among the 16 dyads, contrasting perspectives commonly related to the easiest or hardest QI interventions to implement (8 of 16 dyads) and the practice's success implementing interventions (5 of 16 dyads). There was a nonsignificant, inverse correlation (r = -0.19, p = .47) between the number of in-person QI visits from the facilitator and the total number of contrasting perspectives. Turnover of staff was frequently reported in dyads with contrasting perspectives. Although the impact of contrasting perspectives warrants additional study, planners of QI initiatives using practice facilitation should consider taking steps to minimize contrasting perspectives, or the potential adverse consequences of them, by addressing turnover challenges and encouraging opportunities to share perspectives.

The Balanced Opioid Initiative: protocol for a clustered, sequential, multiple-assignment randomized trial to construct an adaptive implementation strategy to improve guideline-concordant opioid prescribing in primary care

BackgroundRates of opioid prescribing tripled in the USA between 1999 and 2015 and were associated with significant increases in opioid misuse and overdose death. Roughly half of all opioids are prescribed in primary care. Although clinical guidelines describe recommended opioid prescribing practices, implementing these guidelines in a way that balances safety and effectiveness vs. risk remains a challenge. The literature offers little help about which implementation strategies work best in different clinical settings or how strategies could be tailored to optimize their effectiveness in different contexts. Systems consultation consists of (1) educational/engagement meetings with audit and feedback reports, (2) practice facilitation, and (3) prescriber peer consulting. The study is designed to discover the most cost-effective sequence and combination of strategies for improving opioid prescribing practices in diverse primary care clinics.Methods/designThe study is a hybrid type 3 clustered, sequential, multiple-assignment randomized trial (SMART) that randomizes clinics from two health systems at two points, months 3 and 9, of a 21-month intervention. Clinics are provided one of four sequences of implementation strategies: a condition consisting of educational/engagement meetings and audit and feedback alone (EM/AF), EM/AF plus practice facilitation (PF), EM/AF + prescriber peer consulting (PPC), and EM/AF + PF + PPC. The study’s primary outcome is morphine-milligram equivalent (MME) dose by prescribing clinicians within clinics. The study’s primary aim is the comparison of EM/AF + PF + PPC versus EM/AF alone on change in MME from month 3 to month 21. The secondary aim is to derive cost estimates for each of the four sequences and compare them. The exploratory aim is to examine four tailoring variables that can be used to construct an adaptive implementation strategy to meet the needs of different primary care clinics.DiscussionSystems consultation is a practical blend of implementation strategies used in this case to improve opioid prescribing practices in primary care. The blend offers a range of strategies in sequences from minimally to substantially intensive. The results of this study promise to help us understand how to cost effectively improve the implementation of evidence-based practices.Trial registrationNCT 04044521 (ClinicalTrials.gov). Registered 05 August 2019.

12. Practice Facilitation Improves Adolescent Reproductive Health Preventive Services in Pediatric Primary Care

12. Practice Facilitation Improves Adolescent Reproductive Health Preventive Services in Pediatric Primary Care

Reflective practice facilitation within occupational therapy supervision processes: A mixed method study.

Supervisors of occupational therapists play a key role facilitating reflective practice with their supervisees. Through reflective practice, supervisees can optimise their skills in professional reasoning and decision making. The aim of this study was to describe to what degree reflective practice is facilitated within occupational therapy supervision processes. A mixed methods study design was used, collecting data via online surveys and focus groups. Quantitative data were initially analysed using descriptive statistics. Qualitative and quantitative data were then thematically analysed to identify hindering and enabling mechanisms to reflective practice facilitation. Eighteen supervisees and 17 supervising occupational therapists completed the surveys and 14 supervisors participated in a focus group. Half of the supervisees reported that reflective practice was facilitated through supervision only "rarely" or "sometimes." A hindering mechanism to reflective practice facilitation was the awareness of reflective practice models. Enabling mechanisms for reflective practice facilitation included understanding the benefits of reflective practice; recognising the attributes of a reflective practice practitioner; setting up an optimal supervision environment; and flexibly facilitating reflective practice. Findings suggest that reflective practice is not always regularly facilitated through supervision. This may limit opportunities for supervisees to optimise the development of their professional reasoning and clinical skills in the early stages of their careers.

X-ray operators' self-perceived competence, barriers and facilitators in general radiography practice in Western Australia

IntroductionAustralian X-ray operators (XROs) are health workers qualified with a limited radiography licence to perform basic radiography examinations in rural areas of Australia. However, no previous study explored Western Australian (WA) XROs' radiography practice. The purpose of this study was to investigate WA XROs’ self-perceived competence in the general radiography practice, and barriers and facilitators to their competence for determination of appropriate strategies to improve quality and safety of the radiographic service provided by them. MethodsInstitutional review board approval and informed consent from participants were obtained. Interviews were conducted with the WA XROs to obtain demographic information and identify their self-perceived competence in the general radiography practice, and the barriers and facilitators to their competence. A thematic analysis was used to analyse the interview data. ResultsA total of nine interviews were conducted (eight nurses and one paramedic). Participants indicated that they felt highly competent in patient care in radiography and adequately competent in the production of diagnostically acceptable images. The self-perceived barriers include overload of responsibilities, a lack of continuing professional development, and inadequacy of communication, support and XRO courses. The facilitators, post-qualification/course training, support in undertaking examinations, primary professional roles and a small population of the rural and remote areas were identified. ConclusionBased on interview data from nine WA XROs, the perception is that they have competence adequate for providing an acceptable quality radiographic service. Implications for practiceA continuous XRO course review, and provision of a video conference support channel, an online XRO networking forum and additional XROs and/or radiographers working with XROs undertaking the radiography examinations were perceived as the appropriate strategies to improve the WA XROs’ radiography practice. However, these require financial and/or managerial support from governments.

Pro-gender Norms in Norwegian Peace Engagement: Balancing Experiences, Values, and Interests

AbstractThe national self-image of Norway is as a gender-equal and peace-promoting nation. Norwegian gender equality policies grew out of a strong social and political civil society engagement from below combined with equal rights laws as well as quota systems implemented from above by the state. In this paper, we explore the intersection of pro-gender norms and peace engagement in Norwegian foreign policy. While gender mainstreaming has been on the agenda of Norwegian development cooperation for decades, the introduction of pro-gender norms in peace engagement is a more recent phenomenon. How are gender equality norms and concerns understood and promoted by Norwegian peace facilitators in practice. And how are pro-gender experiences, values, and norms balanced in Norwegian peace engagement?

Cardiovascular Disease Guideline Adherence: An RCT Using Practice Facilitation

Practice facilitation is a promising practice transformation strategy, but further examination of its effectiveness in improving adoption of guidelines for multiple cardiovascular disease risk factors is needed. The objective of the study is to determine whether practice facilitation is effective in increasing the proportion of patients meeting the Million Hearts ABCS outcomes: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation intervention. The study used a stepped-wedge cluster RCT design with 4 intervention waves. Data were extracted for 13 quarters between January 1, 2015 and March 31, 2018, which encompassed the control, intervention, and follow-up periods for all waves, and analyzed in 2019. A total of 257 small independent primary care practices in New York City were randomized into 1 of 4 waves. The intervention consisted of practice facilitators conducting at least 13 practice visits over 1 year, focused on capacity building and implementing system and workflow changes to meet cardiovascular disease care guidelines. The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (1) proportion of tobacco users who received a cessation intervention (smokers counseled) and (2) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite). The S measure improved when comparing follow-up with the control period (incidence rate ratio=1.152, 95% CI=1.072, 1.238, p<0.001) and when comparing follow-up with intervention (incidence rate ratio=1.060, 95% CI=1.013, 1.109, p=0.007). Smokers counseled improved when comparing the intervention period with control (incidence rate ratio=1.121, 95% CI=1.037, 1.211, p=0.002). Increasing the impact of practice facilitation programs that target multiple risk factors may require a longer, more intense intervention and greater attention to external policy and practice context. This study is registered at www.clinicaltrials.gov NCT02646488.

Growth Measurement Practices from a National Survey of Neonatal Nurses

PurposeTo describe neonatal nurses' growth measurement practices, attitudes, knowledge, bases of practice knowledge, and barriers and facilitators for changing practice; and to identify differences in practices and knowledge by nursing organization, unit type, education, and experience. Design and methodsA cross-sectional online survey of U.S. neonatal nurses was distributed through two neonatal nursing organizations. ResultsThe survey was completed by 301 nurses. Some evidence-based practices (EBPs) were infrequently reported including recording frontal-occipital head circumference (FOC) and length using 0.1 cm increments (17.9% and 17.6%, respectively); measuring FOC, weight, and length more than once before recording (61.9%, 27.2%, and 39.6%, respectively); and for length, using a length board instead of tape measure (19.4%), with a second person assisting (25.1%), with Frankfort plane head positioning (3.3%), and measuring from crown to heels of both feet (19.1%). Most nurses perceived their measurements as accurate or highly accurate (96.7% for FOC, 99.3% for weight, and 87.1% for length). The mean percentage correct on knowledge items was 68.1%. NICU nurses scored slightly better than well-newborn nurses (mean 69.3% correct vs. 65.1% correct, p = .04). Most based measurement practices on clinical practice guidelines (86.6%) and unit policies and procedures (85.9%). Team culture (33.3%) and insufficient resources (32.6%) were the most common barriers to EBP. The support of nurse managers (70.0%) and unit educators (68.5%) were common facilitators. Conclusions and implicationsKnowledge gaps and practice improvement areas were identified. Results can inform interventions to improve the accuracy and reliability of neonatal growth measurement practices.

Student experiences of live synchronised video feedback in formative assessment

ABSTRACT Effective student feedback is a central issue in higher education and has been closely aligned to satisfaction and overall experience. Technology-enabled models of feedback may have the capacity to overcome some of the limitations that previously made high quality feedback on formative tasks challenging or impractical. This study adopted live synchronised video feedback incorporating digital video recordings of student performance in assessment activities with real-time, synthesised, synchronous tutor audio feedback. Almost 300 unique incidences of technology-enabled feedback on formative assessment were provided during an undergraduate Physical Education and Sports Coaching module. Thematic analysis of group interviews revealed the availability of engaging feedback, the positive impact of technology, and the facilitation of reflective practice as overarching themes. Employment of this feedback strategy enabled the realisation of high quality, frequent, effective, sustainable feedback that positively impacted on students’ experiences of formative assessments leading to their perceived development as learners and reflective practitioners.