Moving Past the Loss: A Longitudinal Qualitative Study of Health Care Staff Experiences of Disinvestment.

This longitudinal qualitative study examines staff experience of disinvestment from a service they are accustomed to providing to their patients. It took place alongside a disinvestment trial that measured the impact of the removal of weekend allied health services from acute wards at two hospitals. Data were gathered from repeated interviews and focus groups with 450 health care staff. We developed a grounded theory, which explains changes in staff perceptions over time and the key modifying factors. Staff appeared to experience disinvestment as loss; a key difference to other operational changes. Early staff experiences of disinvestment were primarily negative, but evolved with time and change-management strategies such as the provision of data, clear and persistent communication approaches, and forums where the big picture context of the disinvestment was robustly discussed. These allowed the disinvestment trial to be successfully implemented at two health services, with high compliance with the research protocol.

Effectiveness of knowledge brokering and recommendation dissemination for influencing healthcare resource allocation decisions: A cluster randomised controlled implementation trial.

BACKGROUND: Implementing evidence into clinical practice is a key focus of healthcare improvements to reduce unwarranted variation. Dissemination of evidence-based recommendations and knowledge brokering have emerged as potential strategies to achieve evidence implementation by influencing resource allocation decisions. The aim of this study was to determine the effectiveness of these two research implementation strategies to facilitate evidence-informed healthcare management decisions for the provision of inpatient weekend allied health services. METHODS AND FINDINGS: This multicentre, single-blinded (data collection and analysis), three-group parallel cluster randomised controlled trial with concealed allocation was conducted in Australian and New Zealand hospitals between February 2018 and January 2020. Clustering and randomisation took place at the organisation level where weekend allied health staffing decisions were made (e.g., network of hospitals or single hospital). Hospital wards were nested within these decision-making structures. Three conditions were compared over a 12-month period: (1) usual practice waitlist control; (2) dissemination of written evidence-based practice recommendations; and (3) access to a webinar-based knowledge broker in addition to the recommendations. The primary outcome was the alignment of weekend allied health provision with practice recommendations at the cluster and ward levels, addressing the adoption, penetration, and fidelity to the recommendations. The secondary outcome was mean hospital length of stay at the ward level. Outcomes were collected at baseline and 12 months later. A total of 45 clusters (n = 833 wards) were randomised to either control (n = 15), recommendation (n = 16), or knowledge broker (n = 14) conditions. Four (9%) did not provide follow-up data, and no adverse events were recorded. No significant effect was found with either implementation strategy for the primary outcome at the cluster level (recommendation versus control ß 18.11 [95% CI -8,721.81 to 8,758.02] p = 0.997; knowledge broker versus control ß 1.24 [95% CI -6,992.60 to 6,995.07] p = 1.000; recommendation versus knowledge broker ß -9.12 [95% CI -3,878.39 to 3,860.16] p = 0.996) or ward level (recommendation versus control ß 0.01 [95% CI 0.74 to 0.75] p = 0.983; knowledge broker versus control ß -0.12 [95% CI -0.54 to 0.30] p = 0.581; recommendation versus knowledge broker ß -0.19 [-1.04 to 0.65] p = 0.651). There was no significant effect between strategies for the secondary outcome at ward level (recommendation versus control ß 2.19 [95% CI -1.36 to 5.74] p = 0.219; knowledge broker versus control ß -0.55 [95% CI -1.16 to 0.06] p = 0.075; recommendation versus knowledge broker ß -3.75 [95% CI -8.33 to 0.82] p = 0.102). None of the control or knowledge broker clusters transitioned to partial or full alignment with the recommendations. Three (20%) of the clusters who only received the written recommendations transitioned from nonalignment to partial alignment. Limitations include underpowering at the cluster level sample due to the grouping of multiple geographically distinct hospitals to avoid contamination. CONCLUSIONS: Owing to a lack of power at the cluster level, this trial was unable to identify a difference between the knowledge broker strategy and dissemination of recommendations compared with usual practice for the promotion of evidence-informed resource allocation to inpatient weekend allied health services. Future research is needed to determine the interactions between different implementation strategies and healthcare contexts when translating evidence into healthcare practice. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000029291.

Health care staff responses to disinvestment-A systematic search and qualitative thematic synthesis.

BACKGROUND: Health care services must deliver high-quality, evidence-based care that represents sound value. Disinvestment is the process of withdrawing resources from any existing health care practices that deliver low gain for their cost and reallocating these toward practices that are more effective, efficient, and cost-effective, thus benefiting patients and the community. PURPOSE: This is the first review to examine the responses of health care staff to disinvestment and investigate the factors that increase the likelihood of these staff accepting disinvestment or reallocation of resources from the health services they provide. METHODS: We conducted a systematic search of five electronic databases using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) framework. A critical appraisal process of the quality of the included studies was performed by two authors. We undertook a thematic synthesis of the qualitative data to develop an overarching narrative. RESULTS: Twelve studies were identified for synthesis and all found that the disinvestment process was challenging and controversial for those health care staff involved. Negative staff reactions to disinvestment identified were anxiety, disempowerment, distrust, and feelings of being dismissed and disrespected. Engagement with disinvestment was observed when staff were invited to participate in a process they considered transparent and in the best interests of the community. PRACTICE RECOMMENDATIONS: Health care staff have a strong professional identity associated with autonomy in their decision making in the provision of health care services. Disinvestment from a service that health care staff can usually choose to provide threatens this identity. Engaging clinical champions to lead change, using rigorous patient outcome data, and transparent decision-making processes may assist health care staff to embrace a new identity as innovators and accept disinvestment in low-value health care.

How do health professionals prioritize clinical areas for implementation of evidence into practice? A cross-sectional qualitative study.

AIM: The current study aimed to identify and understand the reasons why allied health professionals think certain areas of healthcare service provision are a high priority for implementation of evidence into practice. METHODS: A cross-sectional online survey using open-ended questions was conducted between April and May 2018 to identify potential areas for practice change and characterize how participants justified identified areas of priority. Eligible participants were invited by email and included allied health professionals from public or private health services, governance agencies and universities across Australia. Responses were analysed using qualitative content analysis. RESULTS: There were 149 surveys commenced with 146 respondents completing the survey. Of the 146 respondents, 128 were female, 17 male and one unknown. Most of the respondents were between 40 and 49 years old and had a master's degree. In total respondents from more than 13 different professions completed the survey with 110 respondents having more than 10 years of experience in allied health. Ten themes emerged outlining the main reasons respondents felt that their nominated areas of practice change were a high priority for action. These included closing gaps between practice and policy/recommendation/guideline; closing research evidence to practice gaps; improving access to services; perceived cost-effectiveness of service delivery; improving effectiveness of allied health services; current imbalance between service supply and demand; amount of resources involved in service delivery; extent of the health problem; areas of allied health care futility; and equality of workload across allied health professionals. CONCLUSION: The current research provides insights into the decision-making processes of allied health professionals when prioritizing areas of clinical practice for implementation of evidence into practice. Despite an appetite for evidence-based practice, behaviour change was not always implemented in a consistent and systematic manner. There was variability in the type and application of evidence used by allied health professionals to support clinical practice. Whether a more systematic approach to research translation fosters evidence uptake awaits confirmation. Also awaiting investigation are the economic and societal impacts of consistently implementing research-informed clinical decision-making.

Understanding Health Professional Responses to Service Disinvestment: A Qualitative Study.

BACKGROUND: Disinvestment from inefficient health services may be a potential solution to rising healthcare costs, but there has been poor uptake of disinvestment recommendations. This Australian study aims to understand how health professionals react when confronted with a plan to disinvest from a health service they previously provided to their patients. METHODS: This qualitative study took place prior to the disinvestment phase of a trial which removed weekend allied health services from acute hospital wards, to evaluate the effectiveness and cost effectiveness of the service. Observations and focus groups were used to collect data from 156 participants which was analysed thematically. RESULTS: Initial reactions to the disinvestment were almost universally negative, with staff extremely concerned about the impact on the safety and quality of patient care and planning ways to circumvent the trial. Removal of existing services was perceived as a loss and created a direct threat to some clinicians' professional identity. With time, discussion, and understanding of the project's context, some staff moved towards acceptance and perceived the trial as an opportunity, particularly given the service was to be reinstated after the disinvestment. CONCLUSION: Clinicians and health service managers are protective of the services they deliver and can create barriers to disinvestment. Even when services are removed to ascertain their value, health professionals may continue to provide services to their patients. Measuring the impact of the disinvestment may assist staff to accept the removal of a service.

A novel counterbalanced implementation study design: methodological description and application to implementation research.

BACKGROUND: Implementation research is increasingly being recognised for optimising the outcomes of clinical practice. Frequently, the benefits of new evidence are not implemented due to the difficulties applying traditional research methodologies to implementation settings. Randomised controlled trials are not always practical for the implementation phase of knowledge transfer, as differences between individual and organisational readiness for change combined with small sample sizes can lead to imbalances in factors that impede or facilitate change between intervention and control groups. Within-cluster repeated measure designs could control for variance between intervention and control groups by allowing the same clusters to receive a sequence of conditions. Although in implementation settings, they can contaminate the intervention and control groups after the initial exposure to interventions. We propose the novel application of counterbalanced design to implementation research where repeated measures are employed through crossover, but contamination is averted by counterbalancing different health contexts in which to test the implementation strategy. METHODS: In a counterbalanced implementation study, the implementation strategy (independent variable) has two or more levels evaluated across an equivalent number of health contexts (e.g. community-acquired pneumonia and nutrition for critically ill patients) using the same outcome (dependent variable). This design limits each cluster to one distinct strategy related to one specific context, and therefore does not overburden any cluster to more than one focussed implementation strategy for a particular outcome, and provides a ready-made control comparison, holding fixed. The different levels of the independent variable can be delivered concurrently because each level uses a different health context within each cluster to avoid the effect of treatment contamination from exposure to the intervention or control condition. RESULTS: An example application of the counterbalanced implementation design is presented in a hypothetical study to demonstrate the comparison of 'video-based' and 'written-based' evidence summary research implementation strategies for changing clinical practice in community-acquired pneumonia and nutrition in critically ill patient health contexts. CONCLUSION: A counterbalanced implementation study design provides a promising model for concurrently investigating the success of research implementation strategies across multiple health context areas such as community-acquired pneumonia and nutrition for critically ill patients.

Implementation of evidence-based weekend service recommendations for allied health managers: a cluster randomised controlled trial protocol.

BACKGROUND: It is widely acknowledged that health policy and practice do not always reflect current research evidence. Whether knowledge transfer from research to practice is more successful when specific implementation approaches are used remains unclear. A model to assist engagement of allied health managers and clinicians with research implementation could involve disseminating evidence-based policy recommendations, along with the use of knowledge brokers. We developed such a model to aid decision-making for the provision of weekend allied health services. This protocol outlines the design and methods for a multi-centre cluster randomised controlled trial to evaluate the success of research implementation strategies to promote evidence-informed weekend allied health resource allocation decisions, especially in hospital managers. METHODS: This multi-centre study will be a three-group parallel cluster randomised controlled trial. Allied health managers from Australian and New Zealand hospitals will be randomised to receive either (1) an evidence-based policy recommendation document to guide weekend allied health resource allocation decisions, (2) the same policy recommendation document with support from a knowledge broker to help implement weekend allied health policy recommendations, or (3) a usual practice control group. The primary outcome will be alignment of weekend allied health service provision with policy recommendations. This will be measured by the number of allied health service events (occasions of service) occurring on weekends as a proportion of total allied health service events for the relevant hospital wards at baseline and 12-month follow-up. DISCUSSION: Evidence-based policy recommendation documents communicate key research findings in an accessible format. This comparatively low-cost research implementation strategy could be combined with using a knowledge broker to work collaboratively with decision-makers to promote knowledge transfer. The results will assist managers to make decisions on resource allocation, based on evidence. More generally, the findings will inform the development of an allied health model for translating research into practice. TRIAL REGISTRATION: This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) ( ACTRN12618000029291 ). Universal Trial Number (UTN): U1111-1205-2621.

Challenges, uncertainties and perceived benefits of providing weekend allied health services-a managers' perspective.

BACKGROUND: Health services that operate 7 days per week are under pressure to show the increased cost of providing weekend services can be measured in improved patient outcomes. The evidence for weekend allied health services in acute medical and surgical wards is weak and there is wide variation between the services offered at different hospitals. METHODS: This qualitative study was undertaken during a multi-site stepped wedge randomised controlled trial involving twelve acute medical and surgical wards from two Australian hospitals, in which weekend allied health services were removed before being reinstated with a stakeholder driven model. In-depth interviews were conducted with twenty-two staff responsible for managing weekend services at the involved hospitals. Participants were asked about their perceptions of the advantages and disadvantages of providing a weekend allied health service. RESULTS: Managers perceive the services improve patient flow and quality of care and reduce adverse incidents, such as falls and intensive care admissions. They also highlighted the challenges involved in planning, staffing and managing these services and the uncertainties about how to provide it most effectively. CONCLUSIONS: Rising healthcare costs provide opportunity for public and professional debate about the most effective way of providing weekend allied health care services, particularly when health services provide limited other weekend services. Some managers perceived weekend allied health services to improve patient quality of care, but without studies which show these services on acute medical and surgical wards clearly change patient outcomes or provide health economic gains, these resources may need to be redirected. The resources may be better spent in areas with clear evidence to show the addition of weekend allied health services improves patient outcomes, such as on acute assess units and rehabilitation wards.