Strategies for engaging older adults and informal caregivers in health policy development: A scoping review.

BACKGROUND: Care for older adults is high on the global policy agenda. Active involvement of older adults and their informal caregivers in policy-making can lead to cost-effective health and long-term care interventions. Yet, approaches for their involvement in health policy development have yet to be extensively explored. This review maps the literature on strategies for older adults (65+ years) and informal caregivers' involvement in health policy development. METHOD: As part of the European Union TRANS-SENIOR program, a scoping review was conducted using the Joanna Briggs Institute's methodology. Published and grey literature was searched, and eligible studies were screened. Data were extracted from included studies and analysed using the Multidimensional Framework for Patient and Family Engagement in Health and Healthcare. RESULTS: A total of 13 engagement strategies were identified from 11 publications meeting the inclusion criteria. They were categorized as "traditional", "deliberative" and "others", adopting the World Bank's categorization of engagement methods. Older adults and informal caregivers are often consulted to elicit opinions and identify priorities. However, their involvement in policy formulation, implementation and evaluation is unclear from the available literature. Findings indicate that older adults and their informal caregivers do not often have equal influence and shared leadership in policy-making. CONCLUSION: Although approaches for involving older adults and their informal caregivers' involvement were synthesized from literature, we found next to no information about their involvement in policy formulation, implementation and evaluation. Findings will guide future research in addressing identified gaps and guide policy-makers in identifying and incorporating engagement strategies to support evidence-informed policy-making processes that can improve health outcomes for older adults/informal caregivers.

Interventions for the empowerment of older people and informal caregivers in transitional care decision-making: short report of a systematic review.

BACKGROUND: Care transitions across different settings necessitate careful decision-making for all parties involved, yet research indicates that older people and informal caregivers do not have a strong voice in such decisions. OBJECTIVE: To provide a systematic overview of the literature about interventions designed to empower older people and informal caregivers in transitional care decision-making. DESIGN: A systematic review (Prospero Protocol CRD42020167961; funded by the EU's Horizon 2020 program). DATA SOURCES: Five databases were searched: PubMed, EMBASE, Web of Science, PsycINFO, and CINAHL. REVIEW METHODS: The review included evaluations of empowerment in decision-making interventions for older people and informal caregivers facing care transitions, that were published from the inception of the databases up until April 2022. Data extractions were performed by two independent researchers and the quality of studies was assessed with the relevant JBI-critical appraisal tools. A narrative descriptive analysis of the results was performed. FINDINGS: Ten studies, reporting on nine interventions, and including a total of 4642 participants, were included. Interventions included transition preparation tools, support from transition coaches, shared decision-making interventions, and advance care planning. Designs and outcomes assessed were highly diverse and showed a mix of positive and lacking effects. CONCLUSIONS: There is a lack of research on how to empower older people and their informal caregivers in transitional care decision-making. Empowerment in decision-making is usually not central in transitional care interventions, and effects on actual empowerment are mostly not assessed. Conclusions on how to empower older people and informal caregivers in transitional care decision-making cannot be drawn.

Transitional care decision-making through the eyes of older people and informal caregivers: An in-depth interview-based study.

BACKGROUND: Older people with multifaceted care needs often require treatment and complex care across different settings. However, transitional care is often inadequately managed, and older people and their informal caregivers are not always sufficiently heard and/or supported in transitional care decision-making. OBJECTIVE: To explore older people's and informal caregivers' experiences with, views on, and needs concerning empowerment in transitional care decision-making. METHODS: A qualitative descriptive study was conducted in the TRANS-SENIOR consortium's collaborative research using semistructured in-depth interviews between October 2020 and June 2021 in Flanders, Belgium. A total of 29 people were interviewed, including 14 older people and 15 informal caregivers who faced a transition from home to another care setting or vice versa. Data were analysed according to the Qualitative Analysis Guide of Leuven. FINDINGS: Five themes were identified in relation to the participant's experiences, views and needs: involvement in the decision-making process; informal caregivers' burden of responsibility; the importance of information and support; reflections on the decision and influencing factors. CONCLUSIONS: Overall, older people and informal caregivers wished to be more seen, recognised, informed and proactively supported in transitional care decision-making. However, their preferences for greater involvement in decision-making vary and are affected by several factors that are both intrinsic and extrinsic. Therefore, healthcare systems might seek out age-tuned and person-centred empowerment approaches focusing on older people's and informal caregivers' empowerment. For future studies, we recommend developing specific strategies for such empowerment. PATIENT OR PUBLIC CONTRIBUTION: Older persons' representatives were involved in designing the TRANS-SENIOR programme of research, including the current study. Healthcare professionals and nursing care directors were involved in the study design and the selection and recruitment of participants.

Medical Practice Variation Among Primary Care Physicians: 1 Decade, 14 Health Services, and 3,238,498 Patient-Years.

PURPOSE: Variation in medical practice is associated with poorer health outcomes, increased costs, disparities in care, and increased burden on the public health system. In the present study, we sought to describe and assess inter- and intra-primary care physician variation, adjusted for patient and clinic characteristics, over a decade of practice and across a broad range of health services. METHODS: We assessed practice patterns of 251 primary care physicians in southern Israel. For each of 14 health services (imaging tests, cardiac tests, laboratory tests, and specialist visits) we described interphysician and intraphysician variation, adjusted for patient case mix and clinic characteristics, using the coefficient of variation. The adjusted rates were assessed by generalized linear negative-binomial mixed models. RESULTS: The variation between physicians was on average 3-fold greater than the variation of individual physician practice over the years. Services with low utilization were associated with greater inter- and intraphysician variation: rs = (-0.58), P = .03 and rs = (-0.39), P = .17, respectively. In addition, physician utilization ranks averaged over all health services were consistent across the 14 health services (intraclass correlation coefficient, 0.94; 95% CI, 0.93-0.95). CONCLUSIONS: Our results show greater variation in practice patterns between physicians than for individual physicians over the years. It appears that the variation remains high even after adjustment for patient and clinic characteristics and that the individual physician utilization patterns are stable across health services. We propose that personal behavioral characteristics of medical practitioners might explain this variation.

Coping with Psoriasis or Hidradenitis Suppurativa: A Qualitative Study.

OBJECTIVE: Psoriasis and hidradenitis suppurativa (HS) are both chronic inflammatory skin diseases with significant comorbidity. This study aimed to examine how patients with psoriasis or HS cope with their conditions on a personal and psychosocial level, especially in times of clinical exacerbation and symptom deterioration. DESIGN: This qualitative initial study used the phenomenology model to examine patients' lived experiences through the lens of their disease. Via semistructured interviews and content analysis, researchers aimed to describe the subjective reality of people with HS or psoriasis and identify any common issues. PATIENTS AND INTERVENTION: Six open pilot interviews with three patients with HS and three patients with psoriasis uncovered five cardinal domains affecting patients' lives. After completing all the interviews, transcripts were analyzed and classified numerically by frequency of identified terms and keywords. After classifications and data ranking, the main issues were identified and separated into the five domains. MAIN RESULTS: Researchers interviewed 20 patients (10 with psoriasis and 10 with HS). The five domains were distressing symptoms, struggling to cope with the disease, avoiding acute or recurrent eruptions, dealing with eruption, and information sources regarding the disease. Pain and pruritus were the most disturbing symptoms, and the remaining issues concerned the emotional, functional, and financial burden of these chronic conditions. CONCLUSIONS: Even though the symptoms of HS and psoriasis are different, this study reveals common denominators regarding the emotional side of living with chronic skin disease.

How is the use of research evidence in health policy perceived? A comparison between the reporting of researchers and policy-makers.

BACKGROUND: The use of health policy and systems research (HPSR) to inform health policy-making is an international challenge. Incorporating HPSR into decision-making primarily involves two groups, namely researchers (knowledge producers) and policy-makers (knowledge users). The purpose of this study was to compare the perceptions of Israeli health systems and policy researchers and health services policy-makers regarding the role of HPSR, factors influencing its uses and potential facilitators and barriers to HPSR, and implementation of knowledge transfer and exchange (KTE) activities. METHODS: A cross-sectional survey was administered to researchers and policy-makers in Israel. The survey consisted of seven closed questions. Descriptive analyses were carried out for closed-ended questions and comparative analysis were conducted between groups using the χ2 test. RESULTS: A total of 37 researchers and 32 policy-makers responded to the survey. While some views were in alignment, others showed differences. More policy-makers than researchers perceived that the use of HPSR in policy was hindered by practical implementation constraints, whereas more researchers felt that its use was hindered by a lack of coordination between knowledge producers and users. A larger percentage of policy-makers, as compared to researchers, reported that facilitators to the KTE process are in place and a larger percentage of researchers perceived barriers within the KTE environment. A larger percentage of policy-makers perceived KTE activities were in place as compared to researchers. Results also showed large differences in the perceptions of the two groups regarding policy formulation and which organisations they perceived as exerting strong influence on policy-making. CONCLUSIONS: This research demonstrated that there are differences in the perceptions of knowledge producers and users about the process of KTE. Future work should focus on minimising the challenges highlighted here and implementing new KTE activities. These activities could include making the researchers aware of the most effective manner in which to package their results, providing training to policy-makers and assuring that policy-makers have technical access to appropriate databases to search for HPSR. These results underscore the need for the groups to communicate and clarify to each other what they can offer and what they require.

Addressing overuse of health services in health systems: a critical interpretive synthesis.

BACKGROUND: Health systems are increasingly focusing on the issue of 'overuse' of health services and how to address it. We developed a framework focused on (1) the rationale and context for health systems prioritising addressing overuse, (2) elements of a comprehensive process and approach to reduce overuse and (3) implementation considerations for addressing overuse. METHODS: We conducted a critical interpretive synthesis informed by a stakeholder-engagement process. The synthesis identified relevant empirical and non-empirical articles about system-level overuse. Two reviewers independently screened records, assessed for inclusion and conceptually mapped included articles. From these, we selected a purposive sample, created structured summaries of key findings and thematically synthesised the results. RESULTS: Our search identified 3545 references, from which we included 251. Most articles (76%; n = 192) were published within 5 years of conducting the review and addressed processes for addressing overuse (63%; n = 158) or political and health system context (60%; n = 151). Besides negative outcomes at the patient, system and global level, there were various contextual factors to addressing service overuse that seem to be key issue drivers. Processes for addressing overuse can be grouped into three elements comprising a comprehensive approach, including (1) approaches to identify overused health services, (2) stakeholder- or patient-led approaches and (3) government-led initiatives. Key implementation considerations include the need to develop 'buy in' from stakeholders and citizens. CONCLUSIONS: Health systems want to ensure the use of high-value services to keep citizens healthy and avoid harm. Our synthesis can be used by policy-makers, stakeholders and researchers to understand how the issue has been prioritised, what approaches have been used to address it and implementation considerations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014013204 .

Nurses' Perceptions on the Overuse of Health Services: A Qualitative Study.

PURPOSE: To examine whether nurses in Israel think there is overuse of health services, the reasons behind the issue, and ways to reduce the overuse. DESIGN: This was a qualitative study using semistructured interviews. A convenience sample of community care nurses from health clinics across Israel was interviewed. Interviews focused on common areas of overuse, outcomes of overuse, causes of overuse, and potential ways to address the issue. Interviews were recorded, transcribed, and analyzed thematically. FINDINGS: Overuse of antibiotics, imaging, blood tests, and prenatal surveillance were cited as main areas of health service overuse. Participants stated that negative outcomes of overuse could be seen at patient, health system, and population levels. Factors influencing overuse included patient satisfaction, physician fears, and insecurities. Potential interventions included improving physicians' diagnostic confidence, increasing appointment times, providing patients with more treatment information, and implementing a unified computerized system across medical institutions. CONCLUSIONS: Nurses mentioned physicians and patients as main actors in influencing overuse; hence, those populations should be researched further. The health system was identified as the responsible party to address the issue. Health system leaders must consider potential barriers, and investigate interventions that match current culture and context within the health system. CLINICAL RELEVANCE: Nurses can play an essential role in limiting overuse and mitigating subsequent harms to patients.

Making Wise Choices in Health Provision: Initial Exploration of Nurse Perceptions in Israel.

Overuse of health services drives up costs while affecting quality of care. It can also harm patients physically and psychologically through invoking duplicate testing, unnecessary procedures, and psychological stress. The purpose of this study was to understand nurses' perceptions of health care overuse. Nurses perceived that physicians' main considerations when ordering tests are to get additional data to strengthen the diagnosis and "just to be safe." Fear of litigation and patients' desires were important factors. Implementing interventions to reduce overuse will create a more efficient and effective system.

Factors that influence influenza vaccination rates among the elderly: nurses' perspectives.

AIMS: To explore which factors nurses perceive to help and hinder influenza vaccination rates among the elderly. BACKGROUND: Influenza-related illnesses and deaths have disproportionately high prevalence among the elderly. Vaccination is an effective tool to prevent complications. METHODS: Semistructured interviews were conducted with nurses focusing on barriers, facilitators and health care providers' roles in influencing patients to be vaccinated. Interviews were recorded, transcribed and thematically analysed. RESULTS: Nurses identified that the prevalent barriers were fear of the vaccine's side effects, feelings of good health and technical considerations. Facilitators included ease of access and encouragement from health providers, media and social networks. The health care team was influential in raising vaccination rates through direct recommendation, providing concrete information or leading by example. CONCLUSIONS: The health care team can influence patients to vaccinate. Investments in training nurses in the knowledge and skills needed to educate patients, and providing nurses with the necessary resources to engage patients in these discussions may be beneficial. Nurse managers can be instrumental in enhancing nurses' roles and actions to increase influenza vaccination rates among the elderly. IMPLICATIONS FOR NURSING MANAGEMENT: It is essential to reinforce the nurses' role in promoting vaccination among seniors. Given that nurses are the largest number of health professionals, their potential outreach to large numbers of people is strong.

Examining the use of health systems and policy research in the health policymaking process in Israel: views of researchers.

BACKGROUND: All too often, health policy and management decisions are made without making use of or consulting with the best available research evidence, which can lead to ineffective and inefficient health systems. One of the main actors that can ensure the use of evidence to inform policymaking is researchers. The objective of this study is to explore Israeli health systems and policy researchers' views and perceptions regarding the role of health systems and policy research (HSPR) in health policymaking and the barriers and facilitators to the use of evidence in the policymaking process. METHODS: A survey of researchers who have conducted HSPR in Israel was developed. The survey consisted of a demographics section and closed questions, which focused on support both within the researchers' organisations and the broader environment for KTE activities, perceptions on the policymaking process, and the potential influencing factors on the process. The survey was sent to all health systems and policy researchers in Israel from academic institutions, hospital settings, government agencies, the four health insurance funds, and research institutes (n = 107). All responses were analyzed using descriptive statistics. For close-ended questions about level of agreement we combined together the two highest categories (agree or strongly agree) for analysis. RESULTS: Thirty-seven respondents participated in the survey. While many respondents felt that the use of HSPR may help raise awareness on policy issues, the majority of respondents felt that the actual use of HSPR was hindered for many reasons. While facilitators do exist to support the use of research evidence in policymaking, numerous barriers hinder the process such as challenges in government/provider relations, policymakers lacking the expertise for acquiring, assessing, and applying HSPR and priorities in the health system drawing attention away from HSPR. Furthermore, it is perceived by a majority of respondents that the health insurance funds and the physician organisations exert a strong influence in the policymaking process. CONCLUSIONS: Health system and policy researchers in Israel need to be introduced to the benefits and potential advantages of evidence-informed policy in an organised and systematic way. Future research should examine the perceptions of policymakers in Israel and thus we can gain a broader perspective on where the actual issues lie.

The role of nurses and nurse leaders on realizing the clinical, social, and economic return on investment of nursing care.

There is a limited understanding of the significance and the potential contribution that nursing can make through practice, policy, science, and profession to the global health agenda. In this article, we present some of the evidence to demonstrate the clinical, social, and economic returns on investment in nursing. We conclude by addressing the issues that nurse and system leaders need to address in order to achieve these returns on investments, and unless nurses get involved at the leadership level, these returns on investment will not be attained.

Health systems and policy research evidence in health policy making in Israel: what are researchers' practices in transferring knowledge to policy makers?

BACKGROUND: Ensuring the use of research evidence in health system management and policy decisions is an important challenge in this century. Knowledge transfer and exchange (KTE) has emerged as a paradigm to address the challenges and start closing the 'know-do' gap. This area of work is gaining momentum in most developed countries, yet, to date, no work has been performed in Israel within this area. The purpose of this study was to identify which KTE activities health systems and policy researchers in Israel have undertaken. METHODS: A cross-sectional web-based survey of researchers who have conducted health systems and policy research in Israel was developed. The survey consisted of a demographics section, quantitative scales, and open-ended questions. The survey was sent to all health systems and policy researchers in Israel (n = 125). RESULTS: The study response rate (28%) was relatively low as compared to other studies in the same field (range of 42% to 88%). Our survey found that more than a third of the health systems and policy researchers in Israel reported that they were frequently or always involved in the following KTE activities: interactions with target audience through the research process (i.e., during developing a research question or executing the research; 35% to 42%) or through formal or informal meetings during conferences, workshops, or conversations (40%). Less than half of the health systems and policy researchers in Israel are engaged in bridging activities aimed to facilitate target audiences to use research. CONCLUSIONS: This is a fairly new area in Israel and therefore the level of engagement of researchers in KTE activities is not very high. The low response rates could be because KTE is a new field in Israel and minimal KTE initiatives have been undertaken. It is preferable to have higher response rates, yet, after several initiatives, this was the outcome. While the findings are relevant, they may not reflect the total population of health system and policy researchers in Israel. Health system and policy researchers in Israel need to be introduced to the benefits and potential advantages of KTE in an organized and systematic way.

An Evaluation of the Impact of an OPEN Stewardship Generated Feedback Intervention on Antibiotic Prescribing among Primary Care Veterinarians in Canada and Israel.

An interrupted time-series study design was implemented to evaluate the impact of antibiotic stewardship interventions on antibiotic prescribing among veterinarians. A total of 41 veterinarians were enrolled in Canada and Israel and their prescribing data between 2019 and 2021 were obtained. As an intervention, veterinarians periodically received three feedback reports comprising feedback on the participants' antibiotic prescribing and prescribing guidelines. A change in the level and trend of antibiotic prescribing after the administration of the intervention was compared using a multi-level generalized linear mixed-effect negative-binomial model. After the receipt of the first (incidence rate ratios [IRR] = 0.88; 95% confidence interval (CI): 0.79, 0.98), and second (IRR = 0.85; 95% CI: 0.75, 0.97) feedback reports, there was a reduced prescribing rate of total antibiotic when other parameters were held constant. This decline was more pronounced among Israeli veterinarians compared to Canadian veterinarians. When other parameters were held constant, the prescribing of critical antibiotics by Canadian veterinarians decreased by a factor of 0.39 compared to that of Israeli veterinarians. Evidently, antibiotic stewardship interventions can improve antibiotic prescribing in a veterinary setting. The strategy to sustain the effect of feedback reports and the determinants of differences between the two cohorts should be further explored.

Perspectives on low-value care and barriers to de-implementation among primary care physicians: a multinational survey.

BACKGROUND: Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries. METHODS: Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results. RESULTS: Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country's healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient's requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries. CONCLUSIONS: More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country's healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies.

Evaluation of an automated feedback intervention to improve antibiotic prescribing among primary care physicians (OPEN Stewardship): a multinational controlled interrupted time-series study.

Tools to advance antimicrobial stewardship in the primary health care setting, where most antimicrobials are prescribed, are urgently needed. The aim of this study was to evaluate OPEN Stewarship (Online Platform for Expanding aNtibiotic Stewardship), an automated feedback intervention, among a cohort of primary care physicians. We performed a controlled, interrupted time-series study of 32 intervention and 725 control participants, consisting of primary care physicians from Ontario, Canada and Southern Israel, from October 2020 to December 2021. Intervention participants received three personalized feedback reports targeting several aspects of antibiotic prescribing. Study outcomes (overall prescribing rate, prescribing rate for viral respiratory conditions, prescribing rate for acute sinusitis, and mean duration of therapy) were evaluated using multilevel regression models. We observed a decrease in the mean duration of antibiotic therapy (IRR = 0.94; 95% CI: 0.90, 0.99) in intervention participants during the intervention period. We did not observe a significant decline in overall antibiotic prescribing (OR = 1.01; 95% CI: 0.94, 1.07), prescribing for viral respiratory conditions (OR = 0.87; 95% CI: 0.73, 1.03), or prescribing for acute sinusitis (OR = 0.85; 95% CI: 0.67, 1.07). In this antimicrobial stewardship intervention among primary care physicians, we observed shorter durations of therapy per antibiotic prescription during the intervention period. The COVID-19 pandemic may have hampered recruitment; a dramatic reduction in antibiotic prescribing rates in the months before our intervention may have made physicians less amenable to further reductions in prescribing, limiting the generalizability of the estimates obtained.IMPORTANCEAntibiotic overprescribing contributes to antibiotic resistance, a major threat to our ability to treat infections. We developed the OPEN Stewardship (Online Platform for Expanding aNtibiotic Stewardship) platform to provide automated feedback on antibiotic prescribing in primary care, where most antibiotics for human use are prescribed but where the resources to improve antibiotic prescribing are limited. We evaluated the platform among a cohort of primary care physicians from Ontario, Canada and Southern Israel from October 2020 to December 2021. The results showed that physicians who received personalized feedback reports prescribed shorter courses of antibiotics compared to controls, although they did not write fewer antibiotic prescriptions. While the COVID-19 pandemic presented logistical and analytical challenges, our study suggests that our intervention meaningfully improved an important aspect of antibiotic prescribing. The OPEN Stewardship platform stands as an automated, scalable intervention for improving antibiotic prescribing in primary care, where needs are diverse and technical capacity is limited.

Corporate social responsibility and hospitals: US theory, Japanese experiences, and lessons for other countries.

This paper examines the role that corporate social responsibility can play in advancing hospital management. Corporate social responsibility is the integration of social and environmental concerns within business operations. The authors discuss how corporate social responsibility can help hospitals and provide suggestions to hospitals in deciding which corporate social responsibility initiatives to pursue.

Understanding factors affecting the integration of geriatric nurse practitioners into health systems.

BACKGROUND: Geriatric nurse practitioners (NPs) are introduced into health systems to alleviate provider shortages and improve care for older adults. To achieve these goals, geriatric NPs must be integrated into the health system such that they can efficaciously practice. Internationally, little is known about factors affecting the integration of NPs. Such evidence would improve policymaking and the impact of geriatric NPs on care. In Israel, geriatric NPs were recently introduced. Their ongoing integration is an exemplar for other countries. PURPOSE: To identify factors affecting the integration of geriatric NPs in Israel and discuss application of these factors in international policy and research. METHODOLOGY: The Consolidated Framework for Implementation Research guided this qualitative descriptive study. A semistructured interview guide was used to collect data from four professional groups (geriatric NPs, physicians, administrators, and policymakers), which, together, provide a system-level perspective. Factors were identified using deductive content analysis and designated as facilitators, barriers, neutral, or mixed effects. RESULTS: There were 58 participants across the four professional groups. Twenty-eight factors were identified, including patient needs and leadership engagement (facilitators), available information (barrier), culture (mixed), and evidence strength (neutral). Perspectives on several factors differed by the professional group's role in integrating NPs (e.g., costs ). CONCLUSIONS: The barriers highlight lacking interprofessional support from a priori policymaking and communication breakdowns. Policies should reflect priorities of administrators, clinicians, and policymakers. IMPLICATIONS: These factors may inform policymaking in other countries but would be most effective if based on country-specific research. This implementation science approach may inform future studies.