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  • 1.
    Carlfjord, Siw
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Five years experience of an annual course on implementation science: an evaluation among course participants2017In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 12, article id 101Article in journal (Refereed)
    Abstract [en]

    Background: Increasing interest in implementation science has generated a demand for education and training opportunities for researchers and practitioners in the field. However, few implementation science courses have been described or evaluated in the scientific literature. The aim of the present study was to provide a short-and long-term evaluation of the implementation training at Linkoping University, Sweden. Methods: Two data collections were carried out. In connection with the final seminar, a course evaluation form, including six items on satisfaction and suggestions for improvement, was distributed to the course participants, a total of 101 students from 2011 to 2015 (data collection 1), response rate 72%. A questionnaire including six items was distributed by e-mail to the same students in autumn 2016 (data collection 2), response rate 63%. Data from the two data collections were presented descriptively and analysed using the Kirkpatrick model consisting of four levels: reaction, learning, behaviour and results. Results: The students were very positive immediately after course participation, rating high on overall perception of the course and the contents (reaction). The students also rated high on achievement of the course objectives and considered their knowledge in implementation science to be very good and to a high degree due to course participation (learning). Knowledge gained from the course was viewed to be useful (behaviour) and was applied to a considerable extent in research projects and work apart from research activities (results). Conclusions: The evaluation of the doctoral-level implementation science course provided by Linkoping University showed favourable results, both in the short and long term. The adapted version of the Kirkpatrick model was useful because it provided a structure for evaluation of the short-and long-term learning outcomes.

  • 2.
    Dannapfel, Petra
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
    Peolsson, Anneli
    Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis.
    What supports physiotherapists’ use of research in clinical practice? A qualitative study in Sweden2013In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 8Article in journal (Refereed)
    Abstract [en]

    Background

    Evidence-based practice has increasingly been recognized as a priority by professional physiotherapy organizations and influential researchers and clinicians in the field. Numerous studies in the past decade have documented that physiotherapists hold generally favorable attitudes to evidence-based practice and recognize the importance of using research to guide their clinical practice. Research has predominantly investigated barriers to research use. Less is known about the circumstances that actually support use of research by physiotherapists. This study explores the conditions at different system levels that physiotherapists in Sweden perceive to be supportive of their use of research in clinical practice.

    Methods

    Patients in Sweden do not need a referral from a physician to consult a physiotherapist and physiotherapists are entitled to choose and perform any assessment and treatment technique they find suitable for each patient. Eleven focus group interviews were conducted with 45 physiotherapists, each lasting between 90 and 110 minutes. An inductive approach was applied, using topics rather than questions to allow the participants to generate their own questions and pursue their own priorities within the framework of the aim. The data were analyzed using qualitative content analysis.

    Results

    Analysis of the data yielded nine favorable conditions at three system levels supporting the participant’s use of research in clinical practice: two at the individual level (attitudes and motivation concerning research use; research-related knowledge and skills), four at the workplace level (leadership support; organizational culture; research-related resources; knowledge exchange) and three at the extra-organizational level (evidence-based practice guidelines; external meetings, networks, and conferences; academic research and education).

    Conclusions

    Supportive conditions for physiotherapists’ use of research exist at multiple interdependent levels, including the individual, workplace, and extra-organizational levels. Research use in physiotherapy appears to be an interactive and interpretative social process that involves a great deal of interaction with various people, including colleagues and patients.

  • 3.
    Fredriksson, Mio
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Hälso- och sjukvårdsforskning, Sweden.
    Eldh, Ann Catrine
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Hälso- och sjukvårdsforskning, Sweden, Högskolan i Dalarna, Sweden.
    Vengberg, Sofie
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Hälso- och sjukvårdsforskning..
    Dahlström, Tobias
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Hälso- och sjukvårdsforskning, Sweden.
    Halford, Christina
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Hälso- och sjukvårdsforskning, Sweden.
    Wallin, Lars
    Högskolan Dalarna, Sweden, Karolinska Institutet, Sweden.
    Winblad, Ulrika
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Hälso- och sjukvårdsforskning..
    Local politico-administrative perspectives on quality improvement based on national registry data in Sweden: a qualitative study using the Consolidated Framework for Implementation Research.2014In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 9, article id 189Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Through a national policy agreement, over 167 million Euros will be invested in the Swedish National Quality Registries (NQRs) between 2012 and 2016. One of the policy agreement's intentions is to increase the use of NQR data for quality improvement (QI). However, the evidence is fragmented as to how the use of medical registries and the like lead to quality improvement, and little is known about non-clinical use. The aim was therefore to investigate the perspectives of Swedish politicians and administrators on quality improvement based on national registry data.

    METHODS: Politicians and administrators from four county councils were interviewed. A qualitative content analysis guided by the Consolidated Framework for Implementation Research (CFIR) was performed.

    RESULTS: The politicians' and administrators' perspectives on the use of NQR data for quality improvement were mainly assigned to three of the five CFIR domains. In the domain of intervention characteristics, data reliability and access in reasonable time were not considered entirely satisfactory, making it difficult for the politico-administrative leaderships to initiate, monitor, and support timely QI efforts. Still, politicians and administrators trusted the idea of using the NQRs as a base for quality improvement. In the domain of inner setting, the organizational structures were not sufficiently developed to utilize the advantages of the NQRs, and readiness for implementation appeared to be inadequate for two reasons. Firstly, the resources for data analysis and quality improvement were not considered sufficient at politico-administrative or clinical level. Secondly, deficiencies in leadership engagement at multiple levels were described and there was a lack of consensus on the politicians' role and level of involvement. Regarding the domain of outer setting, there was a lack of communication and cooperation between the county councils and the national NQR organizations.

    CONCLUSIONS: The Swedish experiences show that a government-supported national system of well-funded, well-managed, and reputable national quality registries needs favorable local politico-administrative conditions to be used for quality improvement; such conditions are not yet in place according to local politicians and administrators.

  • 4.
    Hasson, Henna
    et al.
    Karolinska Inst, Sweden; Stockholm Cty Council, Sweden.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Augustsson, Hanna
    Karolinska Inst, Sweden; Stockholm Cty Council, Sweden.
    Ingvarsson, Sara
    Karolinska Inst, Sweden.
    Korlen, Sara
    Karolinska Inst, Sweden.
    von Thiele Schwarz, Ulrica
    Karolinska Inst, Sweden; Malardalen Univ, Sweden.
    To do or not to do-balancing governance and professional autonomy to abandon low-value practices: a study protocol2019In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 14, article id 70Article in journal (Refereed)
    Abstract [en]

    BackgroundMany interventions used in health care lack evidence of effectiveness and may be unnecessary or even cause harm, and should therefore be de-implemented. Lists of such ineffective, low-value practices are common, but these lists have little chance of leading to improvements without sufficient knowledge regarding how de-implementation can be governed and carried out. However, decisions regarding de-implementation are not only a matter of scientific evidence; the puzzle is far more complex with political, economic, and relational interests play a role. This project aims at exploring the governance of de-implementation of low-value practices from the perspectives of national and regional governments and senior management at provider organizations.MethodsTheories of complexity science and organizational alignment are used, and interviews are conducted with stakeholders involved in the governance of low-value practice de-implementation, including national and regional governments (focusing on two contrasting regions in Sweden) and senior management at provider organizations. In addition, an ongoing process for governing de-implementation in accordance with current recommendations is followed over an 18-month period to explore how governance is conducted in practice. A framework for the governance of de-implementation and policy suggestions will be developed to guide de-implementation governance.DiscussionThis study contributes to knowledge about the governance of de-implementation of low-value care practices. The study provides rich empirical data from multiple system levels regarding how de-implementation of low-value practices is currently governed. The study also makes a theoretical contribution by applying the theories of complexity and organizational alignment, which may provide generalizable knowledge about the interplay between stakeholders across system levels and how and why certain factors influence the governance of de-implementation. The project employs a solution-oriented perspective by developing a framework for de-implementation of low-value practices and suggesting practical strategies to improve the governance of de-implementation. The framework and strategies can thereafter be evaluated for validity and impact in future studies.

  • 5.
    Hasson, Henna
    et al.
    Karolinska Inst, Sweden; Stockholm Cty Council, Sweden.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Augustsson, Hanna
    Karolinska Inst, Sweden; Stockholm Cty Council, Sweden.
    Schwarz, Ulrica von Thiele
    Karolinska Inst, Sweden; Malardalen Univ, Sweden.
    Empirical and conceptual investigation of de-implementation of low-value care from professional and health care system perspectives: a study protocol2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 67Article in journal (Refereed)
    Abstract [en]

    Background: A considerable proportion of interventions provided to patients lacks evidence of their effectiveness This implies that patients may receive ineffective, unnecessary, or even harmful care Thus, in addition to implementing evidence based practices, there is also a need to abandon interventions that are not based on best evidence, i e, low value care However, research on de implementation is limited, and there is a lack of knowledge about how effective de implementation processes should be earned out The aim of this project is to explore the phenomenon of the de implementation of low value health care practices from the perspective of professionals and the health care system. Methods: Theories of habits and developmental learning in combination with theories of organizational alignment will be used The projects work will be conducted in five steps Step 1 is a scoping review of the literature, and Step 2 has an explorative design involving interviews with health care stakeholders Step 3 has a prospective design in which workplaces and professionals are shadowed during an ongoing de implementation In Step 4, a conceptual framework for de implementation will be developed based on the previous steps In Step 5, strategies for de implementation are identified using a co design approach. Discussion: This project contributes new knowledge to implementation science consisting of empirical data, a conceptual framework, and strategy suggestions on de implementation of low value care The professionals perspectives will be highlighted, including insights into how they make decisions, handle de implementation in daily practice, and what consequences it has on their work Furthermore, the health care system perspective will be considered and new knowledge on how de implementation can be understood across health care system levels will be obtained The theories of habits and developmental learning can also offer insights into how context triggers and reinforces certain behaviors and how factors at the individual and the organizational levels interact The project employs a solution oriented perspective by developing a framework for de implementation of low value practices and suggesting practical strategies to improve de implementation processes at all levels of the health care system The framework and the strategies can thereafter be evaluated for their validity and impact in future studies.

  • 6.
    Kalkan, Almina
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Hallert, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Factors influencing rheumatologists prescription of biological treatment in rheumatoid arthritis: an interview study2014In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 9, no 153Article in journal (Refereed)
    Abstract [en]

    Background: The introduction of biological drugs involved a fundamental change in the treatment of rheumatoid arthritis (RA). The extent to which biological drugs are prescribed to RA patients in different regions in Sweden varies greatly. Previous research has indicated that differences in health care practice at the regional level might obscure differences at the individual level. The objective of this study is to explore what influences individual rheumatologists decisions when prescribing biological drugs. Method: Semi-structured interviews, utilizing closed-and open-ended questions, were conducted with senior rheumatologists, selected through a mix of random and purposive sampling. The interview questions consisted of two parts, with a "parallel mixed method" approach. In the first and main part, open-ended exploratory questions were posed about factors influencing prescription. In the second part, the rheumatologists were asked to rate predefined factors that might influence their prescription decisions. The Consolidated Framework for Implementation Research (CFIR) was used as a conceptual framework for data collection and analysis. Results: Twenty-six rheumatologists were interviewed. A constellation of various factors and their interaction influenced rheumatologists prescribing decisions, including the individual rheumatologists experiences and perceptions of the evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participation in clinical trials. The patient as an actor emerged as an important factor. Hence, factors both at organizational and individual levels influenced the prescribing of biological drugs. The factors should not be seen as individual influences but were described as influencing prescription in an interactive, nonlinear way. Conclusions: Potential factors explaining differences in prescription practice are experience and perception of the evidence on the individual level and the structure of the department and participation in clinical trials on the organizational level. The influence of patient attitudes and preferences and interpretation of scientific evidence seemed to be somewhat contradictory in the qualitative responses as compared to the quantitative rating, and this needs further exploration. An implication of the present study is that in addition to scientific knowledge, attempts to influence prescription behavior need to be multifactorial and account for interactions of factors between different actors.

  • 7.
    Keurhorst, M.
    et al.
    Radboud University of Nijmegen, Netherlands; Saxion University of Appl Science, Netherlands.
    Anderson, P.
    Newcastle University, England; Maastricht University, Netherlands.
    Heinen, M.
    Radboud University of Nijmegen, Netherlands.
    Bendtsen, Preben
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Baena, Begona
    Govt Catalonia, Spain.
    Brzozka, Krzysztof
    State Agency Prevent Alcohol Related Problems, Poland.
    Colom, Joan
    Govt Catalonia, Spain.
    Deluca, Paolo
    Kings Coll London, England.
    Drummond, Colin
    Kings Coll London, England.
    Kaner, Eileen
    Newcastle University, England.
    Kloda, Karolina
    Pomeranian Medical University, Poland.
    Mierzecki, Artur
    Pomeranian Medical University, Poland.
    Newbury-Birch, Dorothy
    University of Teesside, England.
    Okulicz-Kozaryn, Katarzyna
    State Agency Prevent Alcohol Related Problems, Poland.
    Palacio-Vieira, Jorge
    Govt Catalonia, Spain.
    Parkinson, Kathryn
    Newcastle University, England.
    Reynolds, Jillian
    Hospital Clin Barcelona, Spain.
    Ronda, Gaby
    Maastricht University, Netherlands.
    Segura, Lidia
    Govt Catalonia, Spain.
    Slodownik, Luiza
    State Agency Prevent Alcohol Related Problems, Poland.
    Spak, Fredrik
    University of Gothenburg, Sweden.
    van Steenkiste, Ben
    Maastricht University, Netherlands.
    Wallace, Paul
    UCL, England.
    Wolstenholme, Amy
    Kings Coll London, England.
    Wojnar, Marcin
    Medical University of Warsaw, Poland.
    Gual, Antoni
    Hospital Clin Barcelona, Spain.
    Laurant, M.
    Radboud University of Nijmegen, Netherlands; HAN University of Appl Science, Netherlands.
    Wensing, M.
    Radboud University of Nijmegen, Netherlands; University of Heidelberg Hospital, Germany.
    Impact of primary healthcare providers initial role security and therapeutic commitment on implementing brief interventions in managing risky alcohol consumption: a cluster randomised factorial trial2016In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 11, no 96Article in journal (Refereed)
    Abstract [en]

    Background: Brief interventions in primary healthcare are cost-effective in reducing drinking problems but poorly implemented in routine practice. Although evidence about implementing brief interventions is growing, knowledge is limited with regard to impact of initial role security and therapeutic commitment on brief intervention implementation. Methods: In a cluster randomised factorial trial, 120 primary healthcare units (PHCUs) were randomised to eight groups: care as usual, training and support, financial reimbursement, and the opportunity to refer patients to an internet-based brief intervention (e-BI); paired combinations of these three strategies, and all three strategies combined. To explore the impact of initial role security and therapeutic commitment on implementing brief interventions, we performed multilevel linear regression analyses adapted to the factorial design. Results: Data from 746 providers from 120 PHCUs were included in the analyses. Baseline role security and therapeutic commitment were found not to influence implementation of brief interventions. Furthermore, there were no significant interactions between these characteristics and allocated implementation groups. Conclusions: The extent to which providers changed their brief intervention delivery following experience of different implementation strategies was not determined by their initial attitudes towards alcohol problems. In future research, more attention is needed to unravel the causal relation between practitioners attitudes, their actual behaviour and care improvement strategies to enhance implementation science.

  • 8.
    Keurhorst, Myrna N.
    et al.
    Radboud University of Nijmegen, Netherlands.
    Anderson, Peter
    Newcastle University, United Kingdom.
    Spak, Fredrik
    University of Gothenburg, Sweden.
    Bendtsen, Preben
    Linköping University, Department of Medical and Health Sciences, Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Acute Health Care in Linköping. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Segura, Lidia
    Government of Catalonia, Barcelona, Spain.
    Colom, Joan
    Government of Catalonia, Barcelona, Spain.
    Reynolds, Jillian
    Hospital Clin Barcelona, Spain.
    Drummond, Colin
    Kings Coll London, England.
    Deluca, Paolo
    Kings Coll London, England.
    van Steenkiste, Ben
    Maastricht University, Netherlands.
    Mierzecki, Artur
    Pomeranian Medical University, Poland.
    Kloda, Karolina
    Pomeranian Medical University, Poland.
    Wallace, Paul
    UCL, England.
    Newbury-Birch, Dorothy
    Fac Med, England.
    Kaner, Eileen
    Fac Med, England.
    Gual, Toni
    Hospital Clin Barcelona, Spain.
    Laurant, Miranda G H.
    Radboud University of Nijmegen, Netherlands.
    Implementing training and support, financial reimbursement, and referral to an internet-based brief advice program to improve the early identification of hazardous and harmful alcohol consumption in primary care (ODHIN): study protocol for a cluster randomized factorial trial2013In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 8Article in journal (Refereed)
    Abstract [en]

    Background

    The European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers.

    Methods/design

    In a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals’ role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling.

    Discussion

    Effective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.

  • 9.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
    Making sense of implementation theories, models and frameworks2015In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 10, no 53Article in journal (Refereed)
    Abstract [en]

    Background: Implementation science has progressed towards increased use of theoretical approaches to provide better understanding and explanation of how and why implementation succeeds or fails. The aim of this article is to propose a taxonomy that distinguishes between different categories of theories, models and frameworks in implementation science, to facilitate appropriate selection and application of relevant approaches in implementation research and practice and to foster cross-disciplinary dialogue among implementation researchers. Discussion: Theoretical approaches used in implementation science have three overarching aims: describing and/or guiding the process of translating research into practice (process models); understanding and/or explaining what influences implementation outcomes (determinant frameworks, classic theories, implementation theories); and evaluating implementation (evaluation frameworks). Summary: This article proposes five categories of theoretical approaches to achieve three overarching aims. These categories are not always recognized as separate types of approaches in the literature. While there is overlap between some of the theories, models and frameworks, awareness of the differences is important to facilitate the selection of relevant approaches. Most determinant frameworks provide limited "how-to" support for carrying out implementation endeavours since the determinants usually are too generic to provide sufficient detail for guiding an implementation process. And while the relevance of addressing barriers and enablers to translating research into practice is mentioned in many process models, these models do not identify or systematically structure specific determinants associated with implementation success. Furthermore, process models recognize a temporal sequence of implementation endeavours, whereas determinant frameworks do not explicitly take a process perspective of implementation.

  • 10.
    Nilsen, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Preventive and Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, The Institute of Technology.
    Broström, Anders
    Linköping University, Department of Medical and Health Sciences, Nursing Science. Linköping University, Faculty of Health Sciences.
    Ellström, Per-Erik
    Linköping University, HELIX Vinn Excellence Centre. Linköping University, Department of Behavioural Sciences and Learning, Work and Working Life. Linköping University, Department of Behavioural Sciences and Learning, Education and Sociology. Linköping University, Faculty of Arts and Sciences.
    Creatures of habit: accounting for the role of habit in implementation research on clinical behaviour change2012In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 7, no 53Article in journal (Refereed)
    Abstract [en]

    Background: Social cognitive theories on behaviour change are increasingly being used to understand and predict healthcare professionals intentions and clinical behaviours. Although these theories offer important insights into how new behaviours are initiated, they provide an incomplete account of how changes in clinical practice occur by failing to consider the role of cue-contingent habits. This article contributes to better understanding of the role of habits in clinical practice and how improved effectiveness of behavioural strategies in implementation research might be achieved. Discussion: Habit is behaviour that has been repeated until it has become more or less automatic, enacted without purposeful thinking, largely without any sense of awareness. The process of forming habits occurs through a gradual shift in cognitive control from intentional to automatic processes. As behaviour is repeated in the same context, the control of behaviour gradually shifts from being internally guided (e. g., beliefs, attitudes, and intention) to being triggered by situational or contextual cues. Much clinical practice occurs in stable healthcare contexts and can be assumed to be habitual. Empirical findings in various fields suggest that behaviours that are repeated in constant contexts are difficult to change. Hence, interventions that focus on changing the context that maintains those habits have a greater probability of success. Some sort of contextual disturbance provides a window of opportunity in which a behaviour is more likely to be deliberately considered. Forming desired habits requires behaviour to be carried out repeatedly in the presence of the same contextual cues. Summary: Social cognitive theories provide insight into how humans analytically process information and carefully plan actions, but their utility is more limited when it comes to explaining repeated behaviours that do not require such an ongoing contemplative decisional process. However, despite a growing interest in applying behavioural theory in interventions to change clinical practice, the potential importance of habit has not been explored in implementation research.

  • 11.
    Nilsen, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Schildmeijer, Kristina
    Department of Health and Care Sciences, Linnaeus University, Kalmar, Sweden.
    Ericsson, Carin
    Region Östergötland, Heart and Medicine Center.
    Seing, Ida
    Linköping University, Department of Behavioural Sciences and Learning, Education and Sociology. Linköping University, Faculty of Arts and Sciences.
    Birken, Sarah
    Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA.
    Implementation of change in health care in Sweden: a qualitative study of professionals’ change responses2019In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 14, article id 51Article in journal (Refereed)
    Abstract [en]

    Background

    Implementation of evidence-based practices in health care implies change. Understanding health care professionals’ change responses may be critical for facilitating implementation to achieve an evidence-based practice in the rapidly changing health care environment. The aim of this study was to investigate health care professionals’ responses to organizational and workplace changes that have affected their work.

    Methods

    We conducted interviews with 30 health care professionals (physicians, registered nurses and assistant nurses) employed in the Swedish health care system. An inductive approach was applied, using a semi-structured interview guide developed by the authors. We used an analytical framework first published in 1999 to analyze the informants’ change responses in which change responses are perceived as a continuum ranging from a strong acceptance of change to strong resistance to change, describing seven forms of change responses along this continuum. Change response is conceptualized as a tridimensional attitude composed of three components: cognitive, affective and intentional/behavioral.

    Results

    Analysis of the data yielded 10 types of change responses, which could be mapped onto 5 of the 7 change response categories in the framework. Participants did not report change responses that corresponded with the two most extreme forms of responses in the framework, i.e., commitment and aggressive resistance. Most of the change responses were classified as either indifference or passive resistance to changes. Involvement in or support for changes occurred when the health care professionals initiated the changes themselves or when the changes featured their active input and when changes were seen as well founded and well communicated. We did not identify any change responses that could not be fitted into the framework.

    Conclusions

    We found the framework to be useful for a nuanced understanding of how people respond to changes. This knowledge of change responses is useful for the management of changes and for efforts to achieve more successful implementation of evidence-based practices in health care.

  • 12.
    Nilsen, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Ståhl, Christian
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Cairney, Paul
    University of Stirling, Scotland.
    Never the twain shall meet? - a comparison of implementation science and policy implementation research2013In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 8Article in journal (Refereed)
    Abstract [en]

    Background

    Many of society’s health problems require research-based knowledge acted on by healthcare practitioners together with implementation of political measures from governmental agencies. However, there has been limited knowledge exchange between implementation science and policy implementation research, which has been conducted since the early 1970s. Based on a narrative review of selective literature on implementation science and policy implementation research, the aim of this paper is to describe the characteristics of policy implementation research, analyze key similarities and differences between this field and implementation science, and discuss how knowledge assembled in policy implementation research could inform implementation science.

    Discussion

    Following a brief overview of policy implementation research, several aspects of the two fields were described and compared: the purpose and origins of the research; the characteristics of the research; the development and use of theory; determinants of change (independent variables); and the impact of implementation (dependent variables). The comparative analysis showed that there are many similarities between the two fields, yet there are also profound differences. Still, important learning may be derived from several aspects of policy implementation research, including issues related to the influence of the context of implementation and the values and norms of the implementers (the healthcare practitioners) on implementation processes. Relevant research on various associated policy topics, including The Advocacy Coalition Framework, Governance Theory, and Institutional Theory, may also contribute to improved understanding of the difficulties of implementing evidence in healthcare. Implementation science is at a relatively early stage of development, and advancement of the field would benefit from accounting for knowledge beyond the parameters of the immediate implementation science literature.

    Summary

    There are many common issues in policy implementation research and implementation science. Research in both fields deals with the challenges of translating intentions into desired changes. Important learning may be derived from several aspects of policy implementation research.

  • 13.
    Nilsen, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Wallerstedt, Birgitta
    Linnaeus University, Sweden.
    Behm, Lina
    Lund University, Sweden.
    Ahlstroem, Gerd
    Lund University, Sweden.
    Towards evidence-based palliative care in nursing homes in Sweden: a qualitative study informed by the organizational readiness to change theory2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 1Article in journal (Refereed)
    Abstract [en]

    Background: Sweden has a policy of supporting older people to live a normal life at home for as long as possible. Therefore, it is often the oldest, most frail people who move into nursing homes. Nursing home staff are expected to meet the existential needs of the residents, yet conversations about death and dying tend to cause emotional strain. This study explores organizational readiness to implement palliative care based on evidence-based guidelines in nursing homes in Sweden. The aim was to identify barriers and facilitators to implementing evidence-based palliative care in nursing homes. Methods: Interviews were carried out with 20 managers from 20 nursing homes in two municipalities who had participated along with staff members in seminars aimed at conveying knowledge and skills of relevance for providing evidence-based palliative care. Two managers responsible for all elderly care in each municipality were also interviewed. The questions were informed by the theory of Organizational Readiness for Change (ORC). ORC was also used as a framework to analyze the data by means of categorizing barriers and facilitators for implementing evidence-based palliative care. Results: Analysis of the data yielded ten factors (i.e., sub-categories) acting as facilitators and/or barriers. Four factors constituted barriers: the staffs beliefs in their capabilities to face dying residents, their attitudes to changes at work as well as the resources and time required. Five factors functioned as either facilitators or barriers because there was considerable variation with regard to the staffs competence and confidence, motivation, and attitudes to work in general, as well as the managers plans and decisional latitude concerning efforts to develop evidence-based palliative care. Leadership was a facilitator to implementing evidence-based palliative care. Conclusions: There is a limited organizational readiness to develop evidence-based palliative care as a result of variation in the nursing home staffs change efficacy and change commitment as well as restrictions in many contextual conditions. There are considerable individual-and organizational-level challenges to achieving evidence-based palliative care in this setting. The educational intervention represents one of many steps towards developing a culture conducive to evidence-based nursing home palliative care.

  • 14.
    Rycroft-Malone, Jo
    et al.
    Bangor Univ, Wales.
    Seers, Kate
    Univ Warwick, England.
    Eldh, Ann Catrine
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences.
    Cox, Karen
    Fontys Univ Appl Sci, Netherlands.
    Crichton, Nicola
    London South Bank Univ, England.
    Harvey, Gill
    Univ Adelaide, Australia.
    Hawkes, Claire
    Univ Warwick, England.
    Kitson, Alison
    Flinders Univ S Australia, Australia.
    McCormack, Brendan
    Queen Margaret Univ Edinburgh, Scotland.
    McMullan, Christel
    Univ Birmingham, England.
    Mockford, Carole
    Univ Warwick, England.
    Niessen, Theo
    Fontys Univ Appl Sci, Netherlands.
    Slater, Paul
    Ulster Univ, North Ireland.
    Titchen, Angie
    Ulster Univ, North Ireland.
    van der Zijpp, Teatske
    Fontys Univ Appl Sci, Netherlands.
    Wallin, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Div Nursing, Dept Neurobiol Care Sci and Soc, Stockholm, Sweden; Dalarna Univ, Sweden; Univ Gothenburg, Sweden.
    A realist process evaluation within the Facilitating Implementation of Research Evidence (FIRE) cluster randomised controlled international trial: an exemplar2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 138Article in journal (Refereed)
    Abstract [en]

    BackgroundFacilitation is a promising implementation intervention, which requires theory-informed evaluation. This paper presents an exemplar of a multi-country realist process evaluation that was embedded in the first international randomised controlled trial evaluating two types of facilitation for implementing urinary continence care recommendations. We aimed to uncover what worked (and did not work), for whom, how, why and in what circumstances during the process of implementing the facilitation interventions in practice.MethodsThis realist process evaluation included theory formulation, theory testing and refining. Data were collected in 24 care home sites across four European countries. Data were collected over four time points using multiple qualitative methods: observation (372h), interviews with staff (n=357), residents (n=152), next of kin (n=109) and other stakeholders (n=128), supplemented by facilitator activity logs. A combined inductive and deductive data analysis process focused on realist theory refinement and testing.ResultsThe content and approach of the two facilitation programmes prompted variable opportunities to align and realign support with the needs and expectations of facilitators and homes. This influenced their level of confidence in fulfilling the facilitator role and ability to deliver the intervention as planned. The success of intervention implementation was largely dependent on whether sites prioritised their involvement in both the study and the facilitation programme. In contexts where the study was prioritised (including release of resources) and where managers and staff support was sustained, this prompted collective engagement (as an attitude and action). Internal facilitators (IF) personal characteristics and abilities, including personal and formal authority, in combination with a supportive environment prompted by managers triggered the potential for learning over time. Learning over time resulted in a sense of confidence and personal growth, and enactment of the facilitation role, which resulted in practice changes.ConclusionThe scale and multi-country nature of this study provided a novel context to conduct one of the few trial embedded realist-informed process evaluations. In addition to providing an explanatory account of implementation processes, a conceptual platform for future facilitation research is presented. Finally, a realist-informed process evaluation framework is outlined, which could inform future research of this nature.Trial registrationCurrent controlled trials ISRCTN11598502.

  • 15.
    Seers, Kate
    et al.
    Royal College of Nursing Research Institute, School of Health and Social Studies, University of Warwick, Coventry, UK.
    Cox, Karen
    Fontys University of Applied Sciences School of Nursing, Eindhoven, the Netherlands.
    Crichton, Nicola J
    Faculty of Health and Social Care, London South Bank University, UK.
    Edwards, Rhiannon Tudor
    Bangor University, Centre for Economics and Policy in Health/Canolfan Economeg a Pholisi Iechyd, IMSCaR, College of Health and Behavioural Sciences, Bangor University, UK.
    Eldh, Ann Catrine
    Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet and Clinical Research Utilization (CRU), Karolinska University Hospital, Eugeniahemmet, Stockholm, Sweden.
    Estabrooks, Carole A
    Faculty of Nursing, University of Alberta, Edmonton, Canada.
    Harvey, Gill
    Health Management Group, Manchester Business School, University of Manchester, UK.
    Hawkes, Claire
    Bangor University, Centre for Health Related Research, School of Healthcare Sciences, College of Health and Behavioural Sciences, Fron Heulog, Bangor University, UK.
    Kitson, Alison
    School of Nursing, University of Adelaide, Australia.
    Linck, Pat
    Bangor University, Centre for Economics and Policy in Health/Canolfan Economeg a Pholisi Iechyd, IMSCaR, College of Health and Behavioural Sciences, Bangor University, UK.
    McCarthy, Geraldine
    University College Cork, College of Medicine & Health, Cork, Republic of Ireland.
    McCormack, Brendan
    Institute of Nursing Research/School of Nursing, University of Ulster, Newtownabbey, Northern Ireland.
    Mockford, Carole
    Royal College of Nursing Research Institute, School of Health and Social Studies, University of Warwick, Coventry, UK.
    Rycroft-Malone, Jo
    Bangor University, Centre for Health Related Research, School of Healthcare Sciences, College of Health and Behavioural Sciences, Fron Heulog, Bangor University, Bangor, Gwynedd, UK.
    Titchen, Angie
    Fontys University of Applied Sciences School of Nursing, Eindhoven, the Netherlands.
    Wallin, Lars
    Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet and Clinical Research Utilization (CRU), Karolinska University Hospital, Eugeniahemmet, Stockholm, Sweden.
    FIRE (Facilitating Implementation of Research Evidence): a study protocol.2012In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 7, article id 25Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Research evidence underpins best practice, but is not always used in healthcare. The Promoting Action on Research Implementation in Health Services (PARIHS) framework suggests that the nature of evidence, the context in which it is used, and whether those trying to use evidence are helped (or facilitated) affect the use of evidence. Urinary incontinence has a major effect on quality of life of older people, has a high prevalence, and is a key priority within European health and social care policy. Improving continence care has the potential to improve the quality of life for older people and reduce the costs associated with providing incontinence aids.

    OBJECTIVES: This study aims to advance understanding about the contribution facilitation can make to implementing research findings into practice via: extending current knowledge of facilitation as a process for translating research evidence into practice; evaluating the feasibility, effectiveness, and cost-effectiveness of two different models of facilitation in promoting the uptake of research evidence on continence management; assessing the impact of contextual factors on the processes and outcomes of implementation; and implementing a pro-active knowledge transfer and dissemination strategy to diffuse study findings to a wide policy and practice community.

    SETTING AND SAMPLE: Four European countries, each with six long-term nursing care sites (total 24 sites) for people aged 60 years and over with documented urinary incontinence

    METHODS AND DESIGN: Pragmatic randomised controlled trial with three arms (standard dissemination and two different programmes of facilitation), with embedded process and economic evaluation. The primary outcome is compliance with the continence recommendations. Secondary outcomes include proportion of residents with incontinence, incidence of incontinence-related dermatitis, urinary tract infections, and quality of life. Outcomes are assessed at baseline, then at 6, 12, 18, and 24 months after the start of the facilitation interventions. Detailed contextual and process data are collected throughout, using interviews with staff, residents and next of kin, observations, assessment of context using the Alberta Context Tool, and documentary evidence. A realistic evaluation framework is used to develop explanatory theory about what works for whom in what circumstances.

    TRIAL REGISTRATION: Current Controlled Trials ISRCTN11598502.

  • 16.
    Seers, Kate
    et al.
    Univ Warwick, England.
    Rycroft-Malone, Jo
    Bangor Univ, Wales.
    Cox, Karen
    Fontys Univ Appl Sci, Netherlands.
    Crichton, Nicola
    London South Bank Univ, England.
    Edwards, Rhiannon Tudor
    Bangor Univ, Wales.
    Eldh, Ann Catrine
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Estabrooks, Carole A.
    Univ Alberta, Canada.
    Harvey, Gill
    Univ Adelaide, Australia.
    Hawkes, Claire
    Univ Warwick, England.
    Jones, Carys
    Bangor Univ, Wales.
    Kitson, Alison
    Flinders Univ S Australia, Australia.
    McCormack, Brendan
    Queen Margaret Univ, Scotland.
    McMullan, Christel
    Univ Birmingham, England.
    Mockford, Carole
    Univ Warwick, England.
    Niessen, Theo
    Fontys Univ Appl Sci, Netherlands.
    Slater, Paul
    Ulster Univ, North Ireland.
    Titchen, Angie
    Ulster Univ, North Ireland.
    van der Zijpp, Teatske
    Fontys Univ Appl Sci, Netherlands.
    Wallin, Lars
    Karolinska Inst, Sweden; Dalarna Univ, Sweden; Univ Gothenburg, Sweden.
    Facilitating Implementation of Research Evidence (FIRE): an international cluster randomised controlled trial to evaluate two models of facilitation informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 137Article in journal (Refereed)
    Abstract [en]

    BackgroundHealth care practice needs to be underpinned by high quality research evidence, so that the best possible care can be delivered. However, evidence from research is not always utilised in practice. This study used the Promoting Action on Research Implementation in Health Services (PARIHS) framework as its theoretical underpinning to test whether two different approaches to facilitating implementation could affect the use of research evidence in practice.MethodsA pragmatic clustered randomised controlled trial with embedded process and economic evaluation was used. The study took place in four European countries across 24 long-term nursing care sites, for people aged 60years or more with documented urinary incontinence. In each country, sites were randomly allocated to standard dissemination, or one of two different types of facilitation. The primary outcome was the documented percentage compliance with the continence recommendations, assessed at baseline, then at 6, 12, 18, and 24months after the intervention.Data were analysed using STATA15, multi-level mixed-effects linear regression models were fitted to scores for compliance with the continence recommendations, adjusting for clustering.ResultsQuantitative data were obtained from reviews of 2313 records. There were no significant differences in the primary outcome (documented compliance with continence recommendations) between study arms and all study arms improved over time.ConclusionsThis was the first cross European randomised controlled trial with embedded process evaluation that sought to test different methods of facilitation. There were no statistically significant differences in compliance with continence recommendations between the groups. It was not possible to identify whether different types and doses of facilitation were influential within very diverse contextual conditions. The process evaluation (Rycroft-Malone et al., Implementation Science. doi: 10.1186/s13012-018-0811-0) revealed the models of facilitation used were limited in their ability to overcome the influence of contextual factors.Trial registrationCurrent Controlled Trials ISRCTN11598502. Date 4/2/10.The research leading to these results has received funding from the European Unions Seventh Framework Programme (FP7/2007-2013) under grant agreement no. 223646.

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