Knowledge and attitudes of Implementation Support Practitioners-Findings from a systematic integrative review.

BACKGROUND: It requires thoughtful planning and work to successfully apply and sustain research-supported interventions like healthcare treatments, social support, or preventive programs in practice. Implementation support practitioners (ISPs) such as facilitators, technical assistance providers, knowledge brokers, coaches or consultants may be involved to actively support the implementation process. This article presents knowledge and attitudes ISPs bring to their work. METHODS: Building on a previously developed program logic, a systematic integrative review was conducted. Literature was sourced by searching nine electronic data bases, organizational websites, and by launching a call for publications among selected experts and social media. Article screening was performed independently by two researchers, and data from included studies were extracted by members of the research team and quality-assured by the lead researcher. The quality of included RCTs was assessed based on a framework by Hodder and colleagues. Thematic Analysis was used to capture information on knowledge and attitudes of ISPs across the included studies. Euler diagrams and heatmaps were used to present the results. RESULTS: Results are based on 79 included studies. ISPs reportedly displayed knowledge about the clinical practice they work with, implementation / improvement practice, the local context, supporting change processes, and facilitating evidence-based practice in general. In particular, knowledge about the intervention to be implemented and its target population, specific improvement / implementation methods and approaches, organizational structures and sensitivities, training, and characteristics of (good) research was described in the literature. Seven themes describing ISPs' attitudes were identified: 1) professional, 2) motivated / motivating / encouraging / empowering, 3) empathetic / respectful / sensitive, 4) collaborative / inclusive, 5) authentic, 6) creative / flexible / innovative / adaptive, and 7) frank / direct / honest. Pertaining to a professional attitude, being responsive and focused were the most prevalent indicators across included publications. CONCLUSION: The wide range and complexity of knowledge and attitudes found in the literature calls for a comprehensive and systematic approach to collaboratively develop a professional role for ISPs across disciplines. Embedding the ISP role in different health and social welfare settings will enhance implementation capacities considerably.

What implementation strategies are relational? Using Relational Theory to explore the ERIC implementation strategies.

The identification and use of implementation strategies in implementation research and practice have strengthened our understanding of the implementation process as well as the causal pathways between mechanisms, strategies, and implementation outcomes. Although these contributions have advanced the application of strategies, there is still a need to learn more about how strategies might integrate relational exchanges and interactions. The inclusion of critical perspectives has been limited in implementation science, and theories such as Relational Theory can expand our understanding of the relational nature of implementation and enhance rigor through alternative theoretical applications. This study applied Relational Theory through a qualitative directed content analysis of the 73 Expert Recommendations for Implementation Change (ERIC) implementation strategies and examine relational components in strategy descriptions. Three reviewers used the structured approach to review and categorize the implementation strategies based on the Relational and Transactional Strategy Continuum measure, which operationalizes types of interactions, exchanges and alliances. Relational alliance strategies are those in which there is mutual growth and accountability, frequent interaction, shared power, and potential vulnerability. Operational alliances include forms of working exchanges between parties with balanced transactional and relational features. Operational alliances can be somewhat interactive in nature, with minor exchanges and limited accountability. Transactional alliance strategies are mostly uni-directional, influenced by power differentials, and do not require mutual growth, commitment, or exchange; thus, the power of growth is inherently one-sided. Results from the review suggest more implementation strategies with relational alliance features (highly relational, n = 17, semi-relational, n = 19) compared to transactional (highly transactional, n = 9, semi-transactional, n = 10) and 18 strategies coded as operational alliances. The qualitative review revealed opportunities to further expand how relational exchanges are considered within the implementation strategies descriptions, as well as the role of actors and power dynamics within strategy exchanges. The Relational and Transactional Strategy Continuum measure can help practitioners and researchers consider the sequencing, pairing, and impact on outcomes of different types and combinations of strategies in implementation practice and research. Additionally, the measure can support reflection on strategies that promote positive alliances, frequent connections, bi-directional communication, and power sharing.

Building trusting relationships to support implementation: A proposed theoretical model.

This paper presents a theory of change that articulates (a) proposed strategies for building trust among implementation stakeholders and (b) the theoretical linkages between trusting relationships and implementation outcomes. The theory of change describes how trusting relationships cultivate increases in motivation, capability, and opportunity for supporting implementation among implementation stakeholders, with implications for commitment and resilience for sustained implementation, and ultimately, positive implementation outcomes. Recommendations related to the measurement of key constructs in the theory of change are provided. The paper highlights how the development of a testable causal model on trusting relationships and implementation outcomes can provide a bridge between implementation research and implementation practice.

A mixed-methods study to understand the impact of practitioner and organizational factors on fidelity of a child maltreatment prevention intervention in community-based settings.

It has been well-documented that the degree to which interventions are implemented with fidelity in typical service settings has varied. Frequently, interventions are developed and tested in highly controlled or early adopter settings. Less attention has been given to what implementation looks like in usual care, and which factors promote practitioners' ability to implement with fidelity. Individuals and organizations implementing interventions in the real world receive varying levels of external supports and may apply a new intervention unaided. The purpose of this mixed-methods study was to explore factors that support implementation as intended in local community agencies. In the quantitative phase of this study, 32 case planners implementing Family Connections (FC), a child maltreatment preventive intervention, completed a survey about their perceptions of practitioner and organizational factors related to fidelity. The survey data were connected to case-level fidelity scores to understand the relationship between perceptions and fidelity. The qualitative phase of this study involved further exploration with nine case planner interviews and two separate focus groups with supervisors and agency leadership. The results of this study suggest that supervision is a key contributor to a practitioner's ability to implement an intervention in usual care. The quantitative and qualitative results suggest supervision, including supervisors' perseverance, proactiveness, knowledge, availability, and skill reinforcement are important components of enhancing a practitioners' ability to learn and use FC. The quantitative results suggest that the level of education was positively associated with fidelity and perceptions of the intervention's limitations may be negatively related to implementation. Additional components that influence implementation for future research emerged from the qualitative phase related to system expectations and policies, individual practitioner attributes, and characteristics of the intervention. Plain Language Abstract: This mixed-methods study sought to understand the impact of practitioner and organizational factors on fidelity of a child maltreatment prevention intervention in community-based settings. The study first asked case planners about their perceptions of practitioner and organizational factors related to fidelity through an online survey. This survey was connected to case-level fidelity scores to understand the relationship between perceptions and fidelity. The qualitative phase of this study involved further exploration with nine case planner interviews and two separate focus groups with supervisors and agency leadership. The results of this study suggest that supervision is a key contributor to a practitioner's ability to implement a maltreatment prevention intervention. Both methods of the study suggest that various aspects of supervision, including supervisors' perseverance, proactiveness, knowledge, availability, and skill reinforcement are important components of enhancing a practitioner's ability to learn and use the intervention. Additional components that influence the implementation for future research emerged from the qualitative phase related to system expectations and policies, individual practitioner attributes, and characteristics of the intervention.