Can systematic implementation support improve programme fidelity by improving care providers' perceptions of implementation factors? A cluster randomized trial.

BACKGROUND: Investigations of implementation factors (e.g., collegial support and sense of coherence) are recommended to better understand and address inadequate implementation outcomes. Little is known about the relationship between implementation factors and outcomes, especially in later phases of an implementation effort. The aims of this study were to assess the association between implementation success (measured by programme fidelity) and care providers' perceptions of implementation factors during an implementation process and to investigate whether these perceptions are affected by systematic implementation support. METHODS: Using a cluster-randomized design, mental health clinics were drawn to receive implementation support for one (intervention) and not for another (control) of four evidence-based practices. Programme fidelity and care providers' perceptions (Implementation Process Assessment Tool questionnaire) were scored for both intervention and control groups at baseline, 6-, 12- and 18-months. Associations and group differences were tested by means of descriptive statistics (mean, standard deviation and confidence interval) and linear mixed effect analysis. RESULTS: Including 33 mental health centres or wards, we found care providers' perceptions of a set of implementation factors to be associated with fidelity but not at baseline. After 18 months of implementation effort, fidelity and care providers' perceptions were strongly correlated (B (95% CI) = .7 (.2, 1.1), p = .004). Care providers perceived implementation factors more positively when implementation support was provided than when it was not (t (140) = 2.22, p = .028). CONCLUSIONS: Implementation support can facilitate positive perceptions among care providers, which is associated with higher programme fidelity. To improve implementation success, we should pay more attention to how care providers constantly perceive implementation factors during all phases of the implementation effort. Further research is needed to investigate the validity of our findings in other settings and to improve our understanding of ongoing decision-making among care providers, i.e., the mechanisms of sustaining the high fidelity of recommended practices. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03271242 (registration date: 05.09.2017).

The Physical Health Care Fidelity Scale: Psychometric Properties.

Mental health programs need an instrument to monitor adherence to evidence-based physical health care for people with serious mental illness. The paper describes the Physical Health Care Fidelity Scale and study interrater reliability, frequency distribution, sensitivity to change and feasibility. Four fidelity assessments were conducted over 18 months at 13 sites randomized to implementation support for evidence-based physical health care. We found good to excellent interrater reliability, adequate sensitivity for change, good feasibility and wide variability in fidelity across sites after 18 months of implementation. Programs were more successful in establishing Policies stating physical health care standards than in implementing these Policies. The Physical Health Care Fidelity Scale measures and guides implementation of evidence-based physical health care reliably.Trial registration: ClinicalTrials.gov Identifier: NCT03271242.

A qualitative study of the learning processes in young physicians treating suicidal patients: from insecurity to personal pattern knowledge and self-confidence.

BACKGROUND: Little empirical work has been done in studying learning processes among newly educated physicians in the mental health field.The aim of the study was to shed light on the meaning of newly educated physicians' lived experiences of learning processes related to treating suicidal patients. METHODS: Thirteen newly educated physicians narrated their learning experiences while treating suicidal patients in their own practice. The interview texts were transcribed and interpreted using a phenomenological-hermeneutical method inspired by Ricoeur's philosophy. RESULTS: There was one main theme, four themes and eleven sub themes. The main theme was: Being in a transitional learning process. The themes and sub themes were: Preparing for practice (Getting tools and training skills, Becoming aware of one's own attitudes); Gaining experience from treating patients (Treating and following up patients over time, Storing memories and recognizing similarities and differences in patients); Participating in the professional community (Being an apprentice, Relating clinical stories and receiving feedback, Sharing emotions from clinical experiences, Receiving support from peers); and Developing personal competence (Having unarticulated awareness, Having emotional knowledge, Achieving self-confidence). The informants gave a detailed account of the learning process; from recognising similarities and differences in patients they have treated, to accumulating pattern knowledge, which then contributed to their personal feelings of competence and confidence. They described their personal competence with cognitive and emotional elements consisting of both articulated and less articulated knowledge. The findings are interpreted in relation to different learning theories that focus on both individual factors and the interaction with the learning environment. CONCLUSION: This study provides additional information about learning experiences of young physicians during the critical transition phase from medical school to early professional life. Peers are used for both learning and support and might represent a more powerful resource in the learning process than previously recognized. Emotional experiences do not seem to be adequately focused upon in supervision, which obviously has relevance both for learning and for the well-being of young professionals. The study indicates some areas of the educational system that could profitably be expanded including stimulating more systematically to critical reflection on and in practice, attention to feelings in the reflective process and provision of more performance feedback to young physicians.

Dealing with suicidal patients--a challenging task: a qualitative study of young physicians' experiences.

BACKGROUND: Suicide is a major public health problem and treating suicidal patients represents one of the most challenging and complex clinical situations for young physicians. Education of physicians is considered an important strategy in suicide prevention. Young physicians often meet suicidal patients early in their career. Limited information is available about how newly educated physicians experience treating suicidal patients. The aim of the study was to shed light on the meaning of newly educated physicians' lived experiences in treating patients at risk of committing suicide. METHODS: Thirteen newly educated physicians narrated their experiences with suicidal patients. The interview text was transcribed and interpreted using a phenomenological-hermeneutical method inspired by Ricoeur's philosophy. RESULTS: Three main themes and ten themes were noted: Striving for relatedness: relating with the patient; not being able to relate with the patient; Intervening competently: having adequate professional knowledge; performing professionally; having professional values; evaluating one's own competence; and Being emotionally involved: accepting one's own vulnerability; feeling morally indignant; feeling powerless and accepting one's own fallibility. The recently educated physicians clearly described the variety of emotional and ethical dilemmas that arose in meeting suicidal patients and the professional challenge facing this clinical situation. The findings were interpreted in the perspective of communication, clinical decision-making and attention to the professional's emotional reactions. CONCLUSION: An examination of the experiences of young physicians treating suicidal patients reveals three main themes that were a professional challenge for them: Striving for relatedness, Intervening competently and Being emotionally involved. Support for young practitioners that are treating these patients is likely important both to facilitate learning and also for their own well-being. This increased understanding can open up for the patient's suffering and affirm the patient's sense of life. The study provides additional background for educators designing training programs for physicians who will be treating suicidal patients.

[Applied suicide intervention skills training workshop]. / Kurset Førstehjelp ved selvmordsfare.

This article discusses the benefits and limitations of applied suicide intervention skills training (ASIST), a two-day intensive, interactive and practice-dominated workshop designed to help caregivers recognise and estimate risk and learn how to intervene in case of immediate risk of suicide. It could appropriately be compared to training in cardiopulmonary resuscitation. The workshop sensitises participants to attitudes and presents a model for suicide intervention; it is flexible and employs learning aids and audiovisual material in order to encourage a high level of involvement. A growing body of evidence from assessments suggests that the workshop enhances caregivers' sense of readiness for suicide intervention and their actual level of skills for that role. ASIST is a standardized learning experience that uses an effective implementation strategy through which local professionals are trained as instructors. It was developed by LivingWorks Education in Canada in the 1980s. In Norway, Vivat, a training programme originating in the National Suicide Prevention Plan, is in charge of implementation of the workshop and training of instructors.

[Applied suicide intervention--an evaluation]. / Førstehjelp ved selvmordsfare--en evaluering.

BACKGROUND: The department of psychiatry of the University Hospital of North Norway in Tromsø sought to improve suicide prevention skills among medical students through a workshop on applied suicide intervention skills training (ASIST). MATERIAL AND METHODS: Over the course of the academic year 1998/99, 76 medical students attended workshops. Results were assessed through focus group interviews. RESULTS: By the end of the workshop, students reported more professional confidence and better skills in suicide intervention. They found it very useful to get this opportunity to role-play situations and receive feedback on their own behaviour. Working with suicidal patients is a great and challenging responsibility and students were well aware of the importance of paying attention to the boundaries between one's professional and one's private life. They reported that they saw the benefits of working with caregivers from other professions. CONCLUSION: The workshop appears to enhance suicide intervention skills and will continue to be a part of the clerkship in psychiatry at the University of Tromsø.

Developing psychiatric competence during medical education and internship: contributing factors.

The study describes the learning process in psychiatry of medical students through their clerkship and internship, It focused upon the development of students' attitudes to psychiatry, subjective psychiatric competence and self-confidence. The relationships between the participants' background, aspects of the learning environment, their attitudes to psychiatry, psychiatric competence and psychiatric self-confidence were explored in order to develop an empirical model of the learning process.The participants were medical students at the University of Tromsoe, Norway. The study was prospective and based on students' self-reports, Structural panel modelling and growth curve analyses were used to explore the complex interactions between the variables over time and to create a model of the learning processes. The medical students significantly increased their subjective competence and psychiatric self-confidence during their clerkship in psychiatry and maintained them during their internship. Previous psychiatric experience, attitudes towards psychiatry and current psychiatric experience contributed to subjective psychiatric competence, Competence in turn had a positive effect on self-confidence. Interestingly, those with greater subjective competence also appeared to have more psychiatric experience during their internship. An empirical model of the important aspects of the learning process was developed.