How does the external context affect an implementation processes? A qualitative study investigating the impact of macro-level variables on the implementation of goal-oriented primary care.

BACKGROUND: Although the importance of context in implementation science is not disputed, knowledge about the actual impact of external context variables on implementation processes remains rather fragmented. Current frameworks, models, and studies merely describe macro-level barriers and facilitators, without acknowledging their dynamic character and how they impact and steer implementation. Including organizational theories in implementation frameworks could be a way of tackling this problem. In this study, we therefore investigate how organizational theories can contribute to our understanding of the ways in which external context variables shape implementation processes. We use the implementation process of goal-oriented primary care in Belgium as a case. METHODS: A qualitative study using in-depth semi-structured interviews was conducted with actors from a variety of primary care organizations. Data was collected and analyzed with an iterative approach. We assessed the potential of four organizational theories to enrich our understanding of the impact of external context variables on implementation processes. The organizational theories assessed are as follows: institutional theory, resource dependency theory, network theory, and contingency theory. Data analysis was based on a combination of inductive and deductive thematic analysis techniques using NVivo 12. RESULTS: Institutional theory helps to understand mechanisms that steer and facilitate the implementation of goal-oriented care through regulatory and policy measures. For example, the Flemish government issued policy for facilitating more integrated, person-centered care by means of newly created institutions, incentives, expectations, and other regulatory factors. The three other organizational theories describe both counteracting or reinforcing mechanisms. The financial system hampers interprofessional collaboration, which is key for GOC. Networks between primary care providers and health and/or social care organizations on the one hand facilitate GOC, while on the other hand, technology to support interprofessional collaboration is lacking. Contingent variables such as the aging population and increasing workload and complexity within primary care create circumstances in which GOC is presented as a possible answer. CONCLUSIONS: Insights and propositions that derive from organizational theories can be utilized to expand our knowledge on how external context variables affect implementation processes. These insights can be combined with or integrated into existing implementation frameworks and models to increase their explanatory power.

Will the implementation process for goal-oriented primary care succeed? A qualitative study investigating five perceived attributes of goal-oriented care.

Throughout the western world, goal oriented care (GOC) is increasingly promoted as a strategy towards more person-centered, integrated care. The implementation of goal-oriented care not only takes place at the micro-level with individual primary care providers (PCPs) changing their approach, but also requires meso- and macro-level investment. In this study, we zoom in on experiences and actions of various meso- and macro-level actors that are actively engaged with implementing GOC, both within their organization or at the policy level. In-depth interviews were conducted with n = 23 actors from a variety of different organizations (governmental institutions, provider organizations, patient organizations, health/social care organizations, primary care zones/care councils, etc.), using a semi- interview guide inspired by realist interviewing. Three main drivers for implementation were identified: recognition, commitment and coordination. On top of that, results were interpreted through Rogers' Diffusion of Innovations (Dol) theory in which five attributes are discussed that contribute to or hinder implementation success. Our findings can help define actions to support and facilitate the implementation process of an innovation such as GOC.

Exploring readiness for implementing goal-oriented care in primary care using normalization process theory.

AIM: To use normalization process theory (NPT) to build a strategy for the implementation of goal-oriented care (GOC) in primary care in Flanders, Belgium. BACKGROUND: GOC is a possible approach to more coordinated and integrated care and tailors care to patients' personal life goals. The concept has gained interest among policy makers and researchers, but the main drivers for successful implementation are the primary healthcare professionals (PHCPs) who need to see added value of GOC in order to embed it into their daily practice. NPT, developed to understand the processes of implementing new ways of organizing care, offers a useful lens to understand adoption of GOC in primary care practice. METHOD: PHCPs (n = 131) who participated in a 2-hour community meeting on GOC were asked to complete the Normalization MeAsure Development survey. This 23-item survey is based on NPT and describes participants' views about how an intervention would impact their work, their expectations about it, and whether it could become a routine part of their work. FINDINGS: The NPT constructs coherence (sense-making work) and cognitive participation (relational work) showed positive tendency toward implementation of GOC. The participants had an initial understanding on GOC and there was much interest in supporting and start working with this approach. The other constructs collective action (operational work) and reflexive monitoring (appraisal work) will need further efforts to trigger implementation. A common ground is needed to integrate GOC as a common practice which can be achieved by intensive interprofessional collaboration.

How do people living with chronic conditions and their informal caregivers experience primary care? A phenomenological-hermeneutical study.

AIMS AND OBJECTIVES: Gaining insight in how people living with chronic conditions experience primary healthcare within their informal network. BACKGROUND: The primary healthcare system is challenged by the increasing number of people living with chronic conditions. To strengthen chronic care management, literature and policy plans point to a person-centred approach of care (PCC). A first step to identify an appropriate strategy to implement PCC is to gain more insight into the care experiences of these people and their informal caregivers. DESIGN: A phenomenological-hermeneutical philosophy is used. The study is in line with the Consolidated Criteria for Reporting Qualitative Research Guidelines (COREQ). METHOD: In-depth, semi-structured interviews with people living with chronic conditions and informal caregiver dyads (PCDs) (n = 16; 32 individuals) were conducted. An open-ended interview guide was used to elaborate on the PCDs' experiences regarding primary care. A purposive, maximal variation sampling was applied to recruit the participants. RESULTS: Based on sixteen PCDs' reflections, ten themes were identified presenting their experiences with primary care and described quality care as listening and giving attention to what people with chronic conditions want, to what they strive for, and above all to promote their autonomy in a context wherein they are supported by a team of formal caregivers, family and friends. CONCLUSION: To meet the PCDs' needs, self-management should be addressed in an interprofessional environment in which the PCD is an important partner. The findings may facilitate a shift to encourage PCDs in their strengths by enabling them to share their personal goals and by working towards meaningful activities in team collaboration. RELEVANCE TO CLINICAL PRACTICE: Three strategies-self-management support, goal-oriented care, and interprofessional collaboration-have been suggested to improve the PCDs' primary care experiences. These strategies could guide nursing practice in using more and improve high-quality nursing care.

Recommendations for Researchers on Synchronous, Online, Nominal Group Sessions in Times of COVID-19: Fishbone Analysis.

BACKGROUND: In times of COVID-19, we are challenged to experiment with alternative platforms or software to connect people. In particular, the struggle that arose in health research was how to interact with patients and care professionals. The latter is additionally faced with an extreme workload to fight the pandemic crisis. Creative strategies have been developed to continue research among patients and care professionals to improve quality of care. This paper addresses the issue of synchronous, online, nominal group sessions, a common consensus method used for group brainstorming. OBJECTIVE: The purpose of this study was to share our experiences with performing online, nominal group sessions using the video conference software Microsoft Teams. In addition, we aimed to create a practical guide with recommendations for researchers. METHODS: We critically analyzed the procedures for the online nominal group technique, according to the Fishbone methodology. RESULTS: Performing synchronous, online, nominal group sessions is challenging but offers opportunities. Although interaction with and among the attendees complicates the process, the major advantage of online sessions is their accessibility and comfort because of reduced barriers to participation (eg, lower time investment). The role of the moderators is of major importance, and good preparation beforehand is required. Recommendations for future online, nominal research were formulated. CONCLUSIONS: Online, nominal group sessions seem to be a promising alternative for the real-life commonly used technique. Especially during the COVID-19 pandemic, the benefits must be highlighted. More expertise is needed to further refine the practical guide for using digital software in research and to achieve optimal performance.

The Building Blocks of Implementation Frameworks and Models in Primary Care: A Narrative Review.

Background: Our aim is to identify the core building blocks of existing implementation frameworks and models, which can be used as a basis to further develop a framework for the implementation of complex interventions within primary care practices. Within the field of implementation science, various frameworks, and models exist to support the uptake of research findings and evidence-based practices. However, these frameworks and models often are not sufficiently actionable or targeted for use by intervention designers. The objective of this research is to map the similarities and differences of various frameworks and models, in order to find key constructs that form the foundation of an implementation framework or model that is to be developed. Methods: A narrative review was conducted, searching for papers that describe a framework or model for implementation by means of various search terms, and a snowball approach. The core phases, components, or other elements of each framework or model are extracted and listed. We analyze the similarities and differences between the frameworks and models and elaborate on their core building blocks. These core building blocks form the basis of an overarching model that we will develop based upon this review and put into practice. Results: A total of 28 implementation frameworks and models are included in our analysis. Throughout 15 process models, a total of 67 phases, steps or requirements are extracted and throughout 17 determinant frameworks a total of 90 components, constructs, or elements are extracted and listed into an Excel file. They are bundled and categorized using NVivo 12© and synthesized into three core phases and three core components of an implementation process as common elements of most implementation frameworks or models. The core phases are a development phase, a translation phase, and a sustainment phase. The core components are the intended change, the context, and implementation strategies. Discussion: We have identified the core building blocks of an implementation framework or model, which can be synthesized in three core phases and three core components. These will be the foundation for further research that aims to develop a new model that will guide and support intervention designers to develop and implement complex interventions, while taking account contextual factors.