Qualitative Study Of Implementation Research Articles

A qualitative study of implementation and adaptations to Progressive Tinnitus Management (PTM) delivery.

BackgroundTinnitus is a common condition, especially prevalent among military Veterans. Progressive Tinnitus Management (PTM) is an interdisciplinary, structured, stepped-care approach to providing clinical services, including teaching coping skills, to people bothered by tinnitus. PTM has been shown to be effective at reducing functional distress, but implementation of the intervention outside of a research setting has not been studied, even though dissemination is underway within the Veterans Health Administration (VHA) system in the United States. This study was designed to address a gap in knowledge of PTM clinical implementation to date, with a focus on factors facilitating or hindering implementation in VHA audiology and mental health clinic contexts, and whether implementing sites had developed intervention adaptations.MethodsQualitative interviews were conducted with 21 audiology and mental health clinicians and service chiefs across a regional service network. Interviews were transcribed and coded using a hybrid inductive-deductive analytic approach guided by existing implementation research frameworks and then iteratively developed for emergent themes.ResultsPTM prioritization was rare overall, with providers across disciplines challenged by lack of capacity for implementation, but with differences by discipline in challenges to prioritization. Where PTM was prioritized and delivered, this was facilitated by perception of unique value, provider’s own experience of tinnitus, observation/experience with PTM delivery, intervention fit with provider’s skills, and an environment with supportive leadership and adaptive reserve. PTM was frequently adapted to local contexts to address delivery challenges and diversify patient options. Adaptations included shifting from group to individual formats, reducing or combining sessions, and employing novel therapeutic approaches.ConclusionsExisting adaptations highlight the need to better understand mechanisms underlying PTM’s effectiveness, and research on the impact of adaptations on patient outcomes is an important next step. Prioritization of PTM is a key barrier to the scale up and spread of this evidence-based intervention. Developing clinician champions may facilitate dissemination, especially if accompanied by signals of systemic prioritization. Novel approaches exposing clinicians and administrators to PTM may identify and develop clinical champions. Acknowledging the potential for PTM adaptations may make delivery more feasible in the context of existing system constraints and priorities.

E-Mental Health Innovations for Aboriginal and Torres Strait Islander Australians: A Qualitative Study of Implementation Needs in Health Services.

BackgroundElectronic mental health (e-mental health) interventions offer effective, easily accessible, and cost effective treatment and support for mental illness and well-being concerns. However, e-mental health approaches have not been well utilized by health services to date and little is known about their implementation in practice, particularly in diverse contexts and communities.ObjectiveThis study aims to understand stakeholder perspectives on the requirements for implementing e-mental health approaches in regional and remote health services for Indigenous Australians.MethodsQualitative interviews were conducted with 32 managers, directors, chief executive officers (CEOs), and senior practitioners of mental health, well-being, alcohol and other drug and chronic disease services.ResultsThe implementation of e-mental health approaches in this context is likely to be influenced by characteristics related to the adopter (practitioner skill and knowledge, client characteristics, communication barriers), the innovation (engaging and supportive approach, culturally appropriate design, evidence base, data capture, professional development opportunities), and organizational systems (innovation-systems fit, implementation planning, investment).ConclusionsThere is potential for e-mental health approaches to address mental illness and poor social and emotional well-being amongst Indigenous people and to advance their quality of care. Health service stakeholders reported that e-mental health interventions are likely to be most effective when used to support or extend existing health services, including elements of client-driven and practitioner-supported use. Potential solutions to obstacles for integration of e-mental health approaches into practice were proposed including practitioner training, appropriate tool design using a consultative approach, internal organizational directives and support structures, adaptations to existing systems and policies, implementation planning and organizational and government investment.

New modes of governance in Bavaria's alpine forests: The ‘Mountain Forest Initiative’ at work

There is much talk about the need for stakeholder participation and inter-sectoral coordination in forest policy and management. But there is limited understanding about forest agencies' role in the adoption of new governance modes and their contribution to policy delivery. By drawing on a qualitative implementation study of Bavaria's Mountain Forest Initiative in locally-operating forest agencies, the present paper addresses these gaps. The government wants them to establish collaborative arrangements with various stakeholders to facilitate measures for adaptation to climate change in private forests. The cross-case comparison provides detailed empirical insights into distinct sets of activities for making the initiative ‘work’. Stakeholder participation gains a firm basis at the local level if forest agencies develop interest in and generate ownership of prospects for collaborative planning, and tailor these to their needs. The study suggests, however, that involvement of local stakeholders in forest planning is not necessarily instrumental for delivery of effective policies, as reliance on the local level entails the risk that the broader picture of initial policy goals gets lost.

The Embeddedness of Teachers’ Social Networks

Teachers’ social networks can play an important role in teacher learning and organizational change. But what influences teachers’ networks? Why do some teachers have networks that are likely to support individual and organizational change, while others do not? This study is a first step in answering this question. We focus on how district policy influences the quality and configuration of teachers’ social networks. We draw on a longitudinal, qualitative study of implementation of a mathematics curriculum in four schools. We show that district policy (1) shaped the tie formation process, influencing the structure of networks; (2) mobilized resources that teachers subsequently accessed via their networks, influencing the benefits accrued through network exchanges; and (3) introduced interaction routines that interrupted conventional ways that teachers talked together. We thus uncover heretofore unexplored facets of network formation and change. We also provide insight into dimensions of social networks that are amenable to outside intervention.

“One of those areas that people avoid” a qualitative study of implementation in miscarriage management

BackgroundMiscarriage is common and often managed by specialists in the operating room despite evidence that office-based manual vacuum aspiration (MVA) is safe, effective, and saves time and money. Family Medicine residents are not routinely trained to manage miscarriages using MVA, but have the potential to increase access to this procedure. This process evaluation sought to identify barriers and facilitators to implementation of office-based MVA for miscarriage in Family Medicine residency sites in Washington State.MethodsThe Residency Training Initiative in Miscarriage Management (RTI-MM) is a theory-based, multidimensional practice change initiative. We used qualitative methods to identify barriers and facilitators to successful implementation of the RTI-MM.ResultsThirty-six RTI-MM participants completed an interview. We found that the common major barriers to implementation were low volume and a perception of miscarriage as emotional and/or like abortion, while the inclusion of support staff in training and effective champions facilitated successful implementation of MVA services.ConclusionPerceived characteristics of the innovation that may conflict with cultural fit must be explicitly addressed in dissemination strategies and support staff should be included in practice change initiatives. Questions remain about how to best support champions and influence perceptions of the innovation. Our study findings contribute programmatically (to improve the RTI-MM), and to broader theoretical knowledge about practice change and implementation in health service delivery.

Interdisciplinary Team Collaboration during Discharge of Depressed Older Persons: A Norwegian Qualitative Implementation Study.

In order to deliver effective care, it is necessary to organise interdisciplinary activities for older persons who suffer from depressive disorders. This paper evaluated the interdisciplinary team members' perceptions of cooperation in the discharge planning of depressed older persons based on the Chronic Care Model (CCM). A qualitative implementation design was used, data were collected by means of multistage focus groups, and a thematic analysis was performed. Three themes emerged: lack of effective team leadership in the community, the need to change the delivery system, and enhancing self-management support for depressed older persons as well as the participation of their families. It was concluded that nurse managers must find ways of supporting the depressed older persons by better structuring the care, increasing cooperation with organisational leadership, and creating an environment characterised by trust and mutual respect. Distrust can have serious implications for discharge planning collaboration. The development of a common vision of transparency in the organization is important as is a policy of change among leadership and in clinical practice.

“It is a good idea, but…” A qualitative study of implementation of ‘Individual Plan’ in Norwegian mental health care

The aim of the study is to explore and describe what hampers and promotes the implementation of 'Individual Plan'-Norway's answer to integrated care, and to discuss the findings according to implementation theory and research. 'Individual Plan' is a master-plan intended to increase user-participation and provide better coordination of measures for patients in need of extensive and long-term health-care services. Norwegian Health Authorities used a dissemination strategy to implement 'Individual Plan' but managers within health and social care could choose their own way of implementation in their organisation. Twenty-two managers from different clinics and organisational levels within mental health care were interviewed with an in-depth semi-structured interview about the implementation process in their organisation. The analysis was primarily made according to systematic text condensation. The findings describe different implementation processes and how the managers identified with the usefulness of 'Individual Plan' as a tool, choice of practical implementation strategies, the manager's own role, characteristics of organisational culture as well as how the manager considered external factors such as administration, lack of time and resources. The evolved implementation themes are discussed within a frame of existing knowledge and theory. A complex picture of barriers, dilemmas and benefits emerges, both internal and external to an organisation as well as at a personal level that need to be taken into consideration in forthcoming implementation processes to increase the rate of success.

Falling on stony ground? A qualitative study of implementation of clinical guidelines’ prescribing recommendations in primary care

Objectives We aimed to explore key themes for the implementation of guidelines’ prescribing recommendations. Methods We interviewed a purposeful sample of 25 participants in British primary care in late 2000 and early 2001. Thirteen were academics in primary care and 12 were non-academic GPs. We asked about implementation of guidelines for five conditions (asthma, coronary heart disease prevention, depression, epilepsy, menorrhagia) ensuring variation in complexity, role of prescribing in patient management, GP role in prescribing and GP awareness of guidelines. We used the Theory of Planned Behaviour to design the study and the framework method for the analysis. Results Seven themes explain implementation of prescribing recommendations in primary care: credibility of content, credibility of source, presentation, influential people, organisational factors, disease characteristics, and dissemination strategy. Change in recommendations may hinder implementation. This is important since the development of evidence-based guidelines requires change in recommendations. Practitioners do not have a universal view or a common understanding of valid ‘evidence’. Credibility is improved if national bodies develop primary care guidelines with less input from secondary care and industry, and with simple and systematic presentation. Dissemination should target GPs’ perceived needs, improve ownership and get things right in the first implementation attempt. Enforcement strategies should not be used routinely. Conclusions GPs were critical of guidelines’ development, relevance and implementation. Guidelines should be clear about changes they propose. Future studies should quantify the relationship between evidence base of recommendations and implementation, and between change in recommendations and implementation. Small but important costs and side effects of implementing guidelines should be measured in evaluative studies.