Qualitative Study Of Implementation Research Articles

Implementation of digital remote postoperative monitoring in routine practice: a qualitative study of barriers and facilitators.

Remote monitoring can strengthen postoperative care in the community and minimise the burden of complications. However, implementation requires a clear understanding of how to sustainably integrate such complex interventions into existing care pathways. This study aimed to explore perceptions of potential facilitators and barriers to the implementation of digital remote postoperative monitoring from key stakeholders and derive recommendations for an implementable service. A qualitative implementation study was conducted of digital remote postoperative wound monitoring across two UK tertiary care hospitals. All enrolled patients undergoing general surgery, and all staff involved in postoperative care were eligible. Criterion-based purposeful sampling was used to select stakeholders for semi-structured interviews on their perspectives and experiences of digital remote postoperative monitoring. A theory-informed deductive-inductive qualitative analysis was conducted; drawing on normalisation process theory (NPT) to determine facilitators for and barriers to implementation within routine care. There were 28 semi-structured interviews conducted with patients (n = 14) and healthcare professionals (n = 14). Remote postoperative monitoring was perceived to fulfil an unmet need in facilitating the diagnosis and treatment of postoperative complications. Participants perceived clear benefit to both the delivery of health services, and patient outcomes and experience, but some were concerned that this may not be equally shared due to potential issues with accessibility. The COVID-19 pandemic demonstrated telemedicine services are feasible to deliver and acceptable to participants, with examples of nurse-led remote postoperative monitoring currently supported within local care pathways. However, there was a discrepancy between patients' expectations regarding digital health to provide more personalised care, and the capacity of healthcare staff to deliver on these. Without further investment into IT infrastructure and allocation of staff, healthcare staff felt remote postoperative monitoring should be prioritised only for patients at the highest risk of complications. The COVID-19 pandemic has sparked the digital transformation of international health systems, yet the potential of digital health interventions has yet to be realised. The benefits to stakeholders are clear, and if health systems seek to meet governmental policy and patient expectations, there needs to be greater organisational strategy and investment to ensure appropriate deployment and adoption into routine care. NCT05069103.

Process evaluation of the implementation of the assessment of burden of chronic conditions tool in Dutch primary care – lessons from a qualitative implementation study

BackgroundThe Assessment of Burden of Chronic Conditions (ABCC-)tool is developed to facilitate a personalized approach to care in the patient-healthcare provider (HCP) conversation based on shared decision-making and individualized care plans. An effectiveness study highlighted its effect on the perceived quality of care and patient activation. Successful implementation of novel interventions necessitates an understanding of the user’s actual application, user experiences and an evaluation of implementation outcomes. This study aims to evaluate the implementation of the ABCC-tool by HCPs in Dutch primary care.MethodsThis study is the process evaluation of a larger type 1 effectiveness-implementation hybrid trial. Semi-structured interviews with HCPs, who were interventionists in the hybrid trial, were held at three and twelve months after they started using the ABCC-tool. The Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) framework was used to evaluate implementation outcomes. The Implementation domain was further strengthened with an evaluation of implementation fidelity using Carroll’s framework. Inductive coding and thematic analysis were applied to identify relevant participant experiences and implementation outcomes within the RE-AIM framework.ResultsSeventeen HCPs (1 general practitioner, 16 practice nurses) participated in the study, representing 39% of potentially eligible participants. Most HCPs applied the tool after finishing their own routines instead of how it is intended to be used, namely from the beginning of the consultation. HCPs reached 2–6 patients. The ABCC-tool was initially adopted, but twelve HCPs stopped using the tool due to COVID-19 related cancellation of consultations. High fidelity was found for applying the questionnaire and visualization. Low fidelity was present for applying shared decision-making, formulating care goals and monitoring progress. HCPs indicated that maintaning the ABCC-tool depended on accompanying training and implementation support.ConclusionsHCPs applied the ABCC-tool critically different from intended, potentially diminishing its benefits and ease of use. This evaluation stresses the need for a tailored implementation plan that includes more detailed training and guidance on how and when to use the ABCC-tool.

Patient Experience in a Remote Patient Monitoring Program for Hypertension: A Qualitative Study

Abstract BACKGROUND Remote patient monitoring (RPM), which includes out-of-office blood pressure (BP) measurement, coupled with interventions including telehealth and team-based care, is recommended for hypertension (HTN) management. We aimed to assess participant experience with RPM for HTN (RPM-HTN) to understand barriers and facilitators to implementing RPM-HTN in a primary care population where health disparities and social inequities are prevalent. METHODS This is a qualitative implementation study of participants’ experiences with an RPM-HTN program for primary care patients with uncontrolled HTN at an academic health system. We recruited participants with high and low levels of engagement (≥16 or <16 days of transmitted BP readings per month). Semi-structured interviews were conducted, and descriptive statistics and rapid qualitative analysis were used to identify factors affecting the implementation of RPM-HTN, specifically adoption, acceptability, appropriateness, and feasibility. RESULTS Multiple themes emerged from interviews with 14 participants. A doctor’s recommendation and wanting help with BP management were facilitators for engagement, while work conflicts and forgetfulness were barriers to engagement. Participants enjoyed the format and content of nurse and clinical pharmacist phone calls and forming a relationship with the team; expressed improved understanding of HTN and BP management; and appreciated the convenience of remote monitoring. CONCLUSIONS Participants found RPM-HTN acceptable and appropriate, highlighting the team-based and out-of-office approach to care. This study provides actionable targets to overcome feasibility barriers to implementation. In order to increase engagement, RPM policies and procedures should take into account barriers including the quantity of required BP measurements and mechanisms of telehealth communication.

Implementation of a digital health intervention for young people exposed to Technology Assisted Sexual Abuse

BackgroundThe internet has become a place of increased risk of abuse, including sexual abuse, for young people (YP). One potential risk factor to online abuse and exploitation is the ability to mentalise. We developed the i-Minds app, a mentalisation-based digital health intervention (DHI) for YP who have experienced technology assisted sexual abuse (TASA), which we tested in a clinical feasibility trial. Nested within the trial was a qualitative implementation study with clinicians who referred to the trial. ObjectiveTo explore the barriers and enablers to the future integration of i-Minds into clinical practice. Participants and settingTwelve HCPs were recruited from across two trial recruitment sites (Manchester and Edinburgh). MethodsSemi-structured interviews were informed by Normalisation Process Theory (NPT). Framework analysis was used; transcripts were coded deductively to NPT constructs. ResultsPractitioners were positive about the need for, and added value of, the i-Minds app over existing interventions, including other DHIs. While they felt confident with the app, concerns remained around the safety of using the app without practitioner support. i-Minds promoted changes in practitioners' work and impacted online behaviour of YP. There was an identified need for further training and organisational support. ConclusionsPractitioners are aware of TASA but have limited knowledge, skills and tools to work with TASA in clinical practice with YP. There is a need for awareness raising and education about TASA and DHI. i-Minds offers a theory-informed DHI for working with YP exposed to TASA that is acceptable to practitioners and YP.

Mental telehealth in a public child and adolescent psychiatry unit during the pandemic: a qualitative implementation study.

The COVID-19 pandemic led to a prompt implementation of remote care, especially in mental health care. The evidence supporting this modality of care is still emerging, with few qualitative studies describing its implementation in Latin American countries. This study aims to understand the perspectives of therapists and patients regarding the use of telehealth in a child and adolescent mental health unit of a Chilean public service. This is a qualitative study. Two focus groups were defined with 14 professionals, and 16 in-depth interviews were conducted with users of an outpatient child and adolescent psychiatry unit. The data were analyzed using the grounded theory model. In the group of therapists, four main categories emerged: background of mental telehealth, implementation, mental telehealth from the therapist's position, and projections. Three main categories emerged in the patient's group: implementation, evaluation of mental telehealth users, and projections. There are elements in common between the opinions of patients and therapists. Something to note within the patient's group is that, despite accepting remote care and recognizing its positive aspects, aside from the pandemic context, they prefer face-to-face or mixed care.

Implementing systematic melanoma risk assessment and risk-tailored surveillance in a skin cancer focussed dermatology clinic: A qualitative study of feasibility and acceptability to patients and clinic staff.

International bodies recommend that melanoma risk assessment should be integrated into skin cancer care provision, but evidence to support implementation is lacking. To explore the acceptability and feasibility of implementing personalised melanoma risk assessment and tailored patient education and skin surveillance within routine clinical care. This prospective qualitative implementation study was informed by the Theoretical Framework of Acceptability (TFA). Personalised, systematic melanoma risk assessment was implemented in the dermatology clinic at the Melanoma Institute Australia, Sydney, Australia February-May 2021. Pre- and post-implementation observations and semi-structured interviews with patients and staff were conducted (September 2020-March 2021). Observational notes and interview transcript data were analysed thematically using the TFA as a classifying framework. A total of 37 h of observations were made, and 29 patients and 12 clinic staff were interviewed. We found that the delivery of personalised melanoma risk estimates did not impact on patient flow through the clinic. Dermatologists reported that the personalised risk information enhanced their confidence in assessing patient risk and recommending tailored surveillance schedules. Most patients reported that the risk assessment and tailored information were a beneficial addition to their care. Among patients whose risk deviated from their expectations, some reported feeling worried, confused or mistrust in the risk information, including those at lower risk who were recommended to decrease surveillance frequency. It is feasible and acceptable to patients and clinic staff to calculate and deliver personalised melanoma risk information and tailored surveillance as part of routine clinical care within dermatology clinics.

Putting families and local professionals at the hearth of implementation research: a qualitative implementation study on Greenland’s universal parenting programme MANU 0-1 Year

Putting families and local professionals at the hearth of implementation research: a qualitative implementation study on Greenland’s universal parenting programme MANU 0-1 Year

Implementing a perioperative care of older people undergoing surgery (POPS) service: findings from a multi-site qualitative implementation study.

The Perioperative care for Older People undergoing Surgery (POPS) service model is increasingly being implemented across care providers in the English and Welsh National Health Services. The study aimed to produce evidence regarding clinical leaders' activities to implement POPS across different service contexts and to produce generalisable recommendations for future implementation. A qualitative interview study was undertaken across six National Health Services hospitals with established POPS services. Interview participants were recruited on the basis of their direct involvement in the implementation and leadership of the service. Data collection involved semi-structured interviews with 26 people carried out between November 2022 and May 2023. The implementation of POPS is often hampered by a lack of managerial and financial support, and apprehension amongst surgeons and anaesthetist about new ways of working. POPS leaders address these through five interconnected activities, each targeted at a combination of implementation factors. (i) Securing management and financial support. (ii) Professional engagement. (iii) Evidence building as a resource for demonstrating the clinical and operational benefits of POPS. (iv) Communication and engagement activities to promote and legitimise POPS to stakeholder groups. (v) Designated and distributed leadership to promote and coordinate implementation activities and to spread the service to new pathways. Through a combination of activities POPS can be effectively implemented across different organisational contexts. Some aspects of these activities can be guided by shared resources and learning across sites, but others require adaption to local contextual barriers and drivers.

Effect of the Care Programme for the Last Days of Life (CAREFuL) on satisfaction with care as perceived by family caregivers and geriatric nurses. A qualitative implementation study.

The CAREFuL programme based on the Liverpool Care Pathway showed improvements in end-of-life care for patients dying in acute geriatric hospital wards. Importantly, it did not show positive effects on families' satisfaction with care. To gain insight into reasons for absent improved families' satisfaction with care to make adaptations to CAREFuL. We planned a two-step implementation, this study reports the first step. We implemented CAREFuL as tested in the cluster RCT with extra attention to families' involvement, in 6 hospitals. We performed semi-structured interviews with family caregivers (n = 11) and geriatric nurses (n = 11) to ask about their experiences with CAREFuL. We used Nvivo12. This study showed overall positive experiences. Family caregivers were satisfied by seeing their relative being comfortable, and by knowing whom to go to. A shared care approach within the team made nurses comfortable for entering the room. However, families did not always know the rationale for specific actions (e.g. cessation of nutrition) and some wanted to be involved more in the care of their relative. They often had to take initiative for receiving information. Finally, supporting leaflets were not always given or were given without any explanation. We made adaptations to CAREFuL to improve families' satisfaction with care. A trigger sentence is added to support nurses in communicating with families. Professionals need to give a rationale for (not) doing specific actions. Leaflets can be used only as a support for direct communication. This adapted programme will be implemented in another 20 wards.

Acceptability and feasibility of a parent-mediated social-communication therapy for young autistic children in Brazil: A qualitative implementation study of Paediatric Autism Communication Therapy.

Parents of autistic children and health professionals who work with autistic children in Brazil had positive views about introducing Paediatric Autism Communication Therapy as a therapy for autistic children in Brazil. The parents and clinicians also mentioned some difficulties about using Paediatric Autism Communication Therapy in Brazil. We made adaptations to Paediatric Autism Communication Therapy to address these difficulties. Paediatric Autism Communication Therapy is a therapy to support the development of social and communication skills for autistic children aged 2-10 years. The therapy is conducted with the autistic child's parent. Paediatric Autism Communication Therapy has not been used in Brazil before. There are few therapy options available for autistic children in Brazil and we believed that Paediatric Autism Communication Therapy may be useful. We asked three groups of people in Brazil about their views of Paediatric Autism Communication Therapy, after explaining how the therapy works. Group 1 included 18 parents of autistic children aged 2-10 years. Group 2 included 20 health professionals such as psychologists who work with autistic children. Group 3 included 15 parents of autistic children aged 2-7 years who received the Paediatric Autism Communication Therapy. We learned that parents and clinicians felt that Paediatric Autism Communication Therapy would be a beneficial therapy for autistic children in Brazil. We also found out about the challenges of using Paediatric Autism Communication Therapy in Brazil. We used these findings to make small cultural adaptations to Paediatric Autism Communication Therapy to make it more suitable for Brazil.

Measurement and Monitoring of Safety Framework: a qualitative study of implementation through a Canadian learning collaborative

BackgroundThe Measurement and Monitoring of Safety Framework (MMSF) aims to move beyond a narrow focus on measurement and past harmful events as the major focus for safety in healthcare organisations....

Establishing the Geriatric Emergency Department Intervention in Queensland emergency departments: a qualitative implementation study using the i-PARIHS model

BackgroundFrail older adults require specific, targeted care and expedited shared decision making in the emergency department (ED) to prevent poor outcomes and minimise time spent in this chaotic environment. The Geriatric Emergency Department Intervention (GEDI) model was developed to help limit these undesirable consequences. This qualitative study aimed to explore the ways in which two hospital implementation sites implemented the structures and processes of the GEDI model and to examine the ways in which the i-PARIHS (innovation-Promoting Action on Research Implementation in Health Services) framework influenced the implementation.MethodsUsing the i-PARIHS approach to implementation, the GEDI model was disseminated into two hospitals using a detailed implementation toolkit, external and internal facilitators and a structured program of support. Following implementation, interviews were conducted with a range of staff involved in the implementation at both sites to explore the implementation process used. Transcribed interviews were analysed for themes and sub-themes.ResultsThere were 31 interviews with clinicians involved in the implementation, conducted across two hospitals, including interviews with the two external facilitators. Major themes identified included: (i) elements of the GEDI model adopted or (ii) adapted by implementation sites and (iii) factors that affected the implementation of the GEDI model. Both sites adopted the model of care and there was general support for the GEDI approach to the management of frail older people in the ED. Both sites adapted the structure of the GEDI team and the expertise of the team members to suit their needs and resources. Elements such as service focus, funding, staff development and service evaluation were initially adopted but adaptation occurred over time. Resourcing and cost shifting issues at the implementation sites and at the site providing the external facilitators negatively impacted the facilitation process.ConclusionsThe i-PARIHS framework provided a pragmatic approach to the implementation of the evidenced-based GEDI model. Passionate, driven clinicians ensured that successful implementation occurred despite unanticipated changes in context at both the implementation and host facilitator sites as well as the absence of sustained facilitation support.

Experiential family therapy interventions delivered via telemental health: A qualitative implementation study.

Telemental health is a ubiquitous form of treatment that has been around for over a half-century, but there remains minimal research on videoconferencing and relational therapy. The purpose of this qualitative study is to identify how telemental health therapists would implement experiential interventions for children, couples, and families. Twelve trainees (n = 12) that participated in a yearlong telemental health practicum were prompted on three experiential interventions to understand how students adapt relational interventions for telemental health delivery. Intervention prompts included couple de-escalation, family sculpt, and sand tray. Using thematic analysis, five themes emerged to describe the implementation of the interventions: (a) adapting verbal communication skills, (b) grand expressions: adapting nonverbal communication, (c) additional preparations to facilitate interventions, (d) flexibility, and (e) self-of-the-therapist. Study findings, limitations, and clinical implications are discussed in further detail.

Implementing smartphone technology to support relational competence in foster youth: a service provider perspective

ABSTRACT The field of child welfare continues to search for effective ways to mitigate risks foster youth often encounter. Research discoveries about the importance of attachments and relational competence for foster youth support greater well-being. However, little is known about the use of smartphone technology and companion software in foster care as a method in promoting relational competence. This qualitative implementation study sought to explore the perceptions of child welfare providers and other stakeholders regarding how smartphone technology facilitated the ability of foster youth to become more connected with trusted adults. Research results reveal challenges associated with child welfare officials’ purposeful issuance and utilisation of smartphones. Stakeholders and providers viewed these challenges as learning opportunities. Three critical themes uncovered—relationship building, youth empowerment, and normalcy—provide direction for how smartphone technology might be more efficiently tapped relative to future child welfare initiatives.

Evaluating the CYP-IAPT transformation of child and adolescent mental health services in Cambridgeshire, UK: a qualitative implementation study

BackgroundThe Children and Young People’s Improving Access to Psychological Therapies (CYP-IAPT) programme was introduced to transform Child and Adolescent Mental Health Services (CAMHS) across England. The programme comprised a set of principles that local CAMHS partnerships were expected to operationalise and embed with the aim of increasing access to services and improving the quality of care. This study explored how the implementation of the CYP-IAPT programme was executed and experienced by CAMHS professionals in the county of Cambridgeshire (UK), and the extent to which the CYP-IAPT principles were perceived to be successfully embedded into everyday practice.MethodsWe analysed 275 documents relating to the CYP-IAPT programme issued between 2011 and 2015. We also conducted a thematic analysis of 20 qualitative interviews, undertaken at two time points, with professionals from three CAMHS teams in Cambridgeshire. Analysis was informed by implementation science frameworks.ResultsDocument analysis suggested that the CYP-IAPT programme was initially not clearly defined and lacked guidance on how to operationalise key programme principles and apply them in everyday practice. There was also a degree of programme evolution over time, which made it difficult for local stakeholders to understand the scope and aims of CYP-IAPT. Interviews with staff showed low coherent understanding of the programme, variable levels of investment among stakeholders and difficulties in collaborative working. Barriers and facilitators to programme implementation were identified at individual, service and strategic levels. These in turn impacted the local implementation efforts and sustainability of the programme in Cambridgeshire.ConclusionsWe identified factors relating to programme design and national and local implementation planning, as well as features of inner and outer context, which impacted on the delivery and sustainability of the programme. These findings can be drawn upon to inform the development and delivery of other local and national quality improvement (QI) initiatives relating to children and young people’s mental health.

The introduction of a safety checklist in two UK hospital emergency departments: A qualitative study of implementation and staff use.

Aims and objectivesTo explore the extent to which a checklist designed to support patient safety in hospital Emergency Departments was recognised and used by staff.BackgroundPatient crowding in UK Emergency Departments makes it difficult for staff to monitor all patients for signs of clinical deterioration. An Emergency Department Safety Checklist was developed at a UK hospital to ensure patients are regularly monitored. It was subsequently implemented in six hospitals and recommended for use across the National Health Service in England.MethodsThis was a qualitative study in two UK hospital Emergency Departments. Data collection consisted of sixty‐six hours of nonparticipant observation and interviews with twenty‐six staff. Observations were sampled across different days and times. Interviews sampled a range of staff. Data were analysed thematically. The study was undertaken in accordance with COREQ guidelines.ResultsStaff described the Emergency Department Safety Checklist as a useful prompt and reminder for monitoring patients' vital signs and other aspects of care. It was also reported as effective in communicating patient care status to other staff. However, completing the checklist was also described as a task which could be overlooked during busy periods. During implementation, the checklist was promoted to staff in ways that obscured its core function of maintaining patient safety.ConclusionsThe Emergency Department Safety Checklist can support staff in maintaining patient safety. However, it was not fully recognised by staff as a core component of everyday clinical practice.Relevance to clinical practiceThe Emergency Department Safety Checklist is a response to an overcrowded environment. To realise the potential of the checklist, emergency departments should take the following steps during implementation: (a) focus on the core function of clinical safety, (b) fully integrate the checklist into the existing workflow and (c) employ a departmental team‐based approach to implementation and training.

Design and pilot testing of a church-based intervention to address interpersonal and intrapersonal barriers to uptake of family planning in rural Tanzania: a qualitative implementation study

BackgroundUse of family planning (FP) saves the lives of mothers and children, and contributes to better economic outcomes for households and empowerment for women. In Tanzania, the overall unmet need...

Commentary on “Pediatric Physical Therapists' Use of the Congenital Muscular Torticollis Clinical Practice Guidelines: A Qualitative Implementation Study”

“How could I apply this information?” A majority of the 13 therapists participating in the study had a positive view of the 2013 congenital muscular torticollis (CMT) clinical practice guideline (CPG)1 and were able to implement the CPG in a variety of settings. The CPG1 had an effect on the participants' CMT-related examination and discharge practices and a lesser effect on participants' intervention practices. Identifying aspects of the 2013 CMT CPG,1 which participants found to be helpful (eg, the CMT classification grades and decision tree) and frustrating (ie, the perception that the CPG1 should include certain interventions), provides insights into educational needs regarding use of CPGs that may help therapists to integrate CPGs into their practice. “What should I be mindful about when applying this information?” Although this study was well designed, having more than 1 researcher involved in conducting the interviews and conducting the interviews in a face-to-face format (either in-person or through video conferencing) would have reduced the risk for bias. As indicated in the article discussion, the degree and consistency to which participating therapists used and applied the 2013 CMT CPG1 may not be representative of all pediatric therapists who work with children who have CMT. Additional research involving participants with varying levels of experience or inexperience with the CMT CPG1,2 would capture a broader range of opinions and may help to identify pertinent factors related to why some therapists use the CMT CPG1,2 while others do not. Future research exploring therapists' perceptions related to use of the updated 2018 CMT CPG2 and related online Implementation Resources3 also would be beneficial. Lisa K. Kenyon, PT, DPT, PhD, PCS Department of Physical Therapy, Grand Valley State University Grand Rapids, Michigan Micah Huegel, PT, DPT Mary Free Bed Rehabilitation Hospital Grand Rapids, Michigan

Qualitative study of implementation of patient self-reported measures in a consultation-liaison psychiatry practice.

Understanding of barriers and successes associated with the implementation of electronic patient self-reported measures (ePSRMs) within clinical settings are limited and have not been pursued utilizing implementation science frameworks. This qualitative study is designed to assess staff perceptions of an ePSRM implementation. The study took place in an academic hospital's Consultation Liaison Psychiatry practice. Qualitative interviews were conducted with the staff and clinicians from the practice. Participants were directly involved with the implementation and use of the ePSRM system within the Psychiatry practice. Interviews were structured around the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Participants reported increased patient engagement as well as efficiency and time savings. The intervention was perceived to be more challenging for older patients. Facilitators include communicating the ePSRM to patients prior to the care visit, having enough trained staff or super-users who can assist with technical problems, and having a shorter questionnaire. Overall, assessment of the ePSRM implementation was positive. Staff and clinicians indicated benefits in time, effectiveness, and improvements in patient treatment. Results indicate that defining how the system would fit within the clinical workflow was key, as was a flexible and user-friendly technology platform. The ePSRM implementation was dependent upon clinical involvement and interest in adoption, while barriers were associated with technical challenges as well as some patient difficulties, such as cognitive impairment. The use of the RE-AIM framework is valuable as it allows for systematic assessment of the implementation and identifies areas in that implementation has succeeded or is lacking.

Protocol for evaluating and implementing a pragmatic value-based healthcare management model for patients with inflammatory arthritis: a Danish population-based regional cohort and qualitative implementation study

IntroductionThe provision of healthcare for patients with inflammatory arthritis occurs in the context of somewhat conflicting targets, values and drivers. Therefore, there is a need for introducing ‘value-based healthcare’ defined...