Adaptations to practice and resilience in a paediatric major trauma centre during a mass casualty incident.

BACKGROUND: Innovation and human adaptation in the face of unfolding catastrophe is the cornerstone of an effective systemwide response. Capturing, analysing, and disseminating this is fundamental in developing resilience for future events. The aim of this study was to understand the characteristics of adaptations to practice early in a paediatric major trauma centre during a mass casualty incident. METHODS: A qualitative interview study of 40 healthcare staff at a paediatric major trauma centre in the immediate aftermath of a terrorist bombing was conducted. An inductive thematic analysis approach was used, followed by a deductive analysis of the identified adaptations informed by constructs of resilience engineering. RESULTS: Five themes of adaptations to practice that enhanced the resilient performance of the hospital were identified: teamworking; psychologically supporting patients, families, and staff; reconfiguring infrastructure; working around the hospital electronic systems; and maintaining hospital safety. Examples of resilience potential in terms of respond, monitor, anticipate, and learn are presented. CONCLUSIONS: Our study shows how adaptations to practice sustained the resilient performance of a paediatric major trauma centre during a mass casualty incident. Rapid, early capture of these data during a mass casualty incident provides key insights into enhancing future emergency preparedness, response, and resilience planning.

National governance of de-implementation of low-value care: a qualitative study in Sweden.

BACKGROUND: The de-implementation of low-value care (LVC) is important to improving patient and population health, minimizing patient harm and reducing resource waste. However, there is limited knowledge about how the de-implementation of LVC is governed and what challenges might be involved. In this study, we aimed to (1) identify key stakeholders' activities in relation to de-implementing LVC in Sweden at the national governance level and (2) identify challenges involved in the national governance of the de-implementation of LVC. METHODS: We used a purposeful sampling strategy to identify stakeholders in Sweden having a potential role in governing the de-implementation of LVC at a national level. Twelve informants from nine stakeholder agencies/organizations were recruited using snowball sampling. Semi-structured interviews were conducted, transcribed and analysed using inductive thematic analysis. RESULTS: Four potential activities for governing the de-implementation of LVC at a national level were identified: recommendations, health technology assessment, control over pharmaceutical products and a national system for knowledge management. Challenges involved included various vested interests that result in the maintenance of LVC and a low overall priority of working with the de-implementation of LVC compared with the implementation of new evidence. Ambiguous evidence made it difficult to clearly determine whether a practice was LVC. Unclear roles, where none of the stakeholders perceived that they had a formal mandate to govern the de-implementation of LVC, further contributed to the challenges involved in governing that de-implementation. CONCLUSIONS: Various activities were performed to govern the de-implementation of LVC at a national level in Sweden; however, these were limited and had a lower priority relative to the implementation of new methods. Challenges involved relate to unfavourable change incentives, ambiguous evidence, and unclear roles to govern the de-implementation of LVC. Addressing these challenges could make the national-level governance of de-implementation more systematic and thereby help create favourable conditions for reducing LVC in healthcare.

Prioritizing and meeting life-threateningly ill patients' fundamental care needs in the emergency room-An interview study with registered nurses.

AIM: To explore how registered nurses in the emergency room describe their work approach and prerequisites for meeting life-threateningly ill patients' care needs from the perspective of a person-centred fundamental care framework. DESIGN: A descriptive, qualitative interview study. METHOD: Individual interviews were carried out with 14 registered nurses with experience of working in an emergency room in Sweden, during 2019. Data were analysed using thematic analysis, according to Braun and Clarke. The COREQ checklist was used for reporting the findings. RESULTS: Three themes were identified: Task-oriented nursing care based on structured guidelines and checklists; Fundamental care not being promoted or prioritized in the emergency room; and The organization and responsibilities for providing person-centred fundamental care are unclear. Results showed that registered nurses structure their work approach based on prevailing organizational prerequisites as well as personal ones. Meeting patients' fundamental care needs was not always prioritized; their physical needs were met to a greater extent than their relational and psychosocial needs. Registered nurses did not prioritize fundamental care when the organization did not. CONCLUSION: From the registered nurses' perspective, they structured their work based on the prevailing conditions for meeting patients' fundamental care needs. The organizational structure does not clearly state that fundamental care should be performed in the emergency room, and the registered nurses' work approach there for meeting patients' fundamental care needs is not adapted to provide patients with person-centred care. IMPACT: To date, little is known about registered nurses' work approach and prerequisites in meeting life-threateningly ill patients' fundamental care needs in the emergency room. Our findings indicate that the organizational structure is pivotal in supporting registered nurses to provide person-centred fundamental care. The knowledge from this study can be used in emergency care settings to facilitate person-centred fundamental care and thereby avoid fundamental care being missed.

The work of having a chronic condition: development and psychometric evaluation of the distribution of co-care activities (DoCCA) scale.

BACKGROUND: Chronic care involves multiple activities that can be performed by individuals and healthcare staff as well as by other actors and artifacts, such as eHealth services. Thus, chronic care management can be viewed as a system where the individual interacts with people and eHealth services performing activities to maintain or improve health and functioning, called co-care. Yet, the system perspective is not reflected in concepts such as person-centered care and shared decision making. This limits the understanding of individuals' global experience of chronic care management and subsequently the ability to optimize chronic care. The aim of this study was threefold: (1) to propose a theory-based operationalization of co-care for chronic care management, (2) to develop a scale to measure co-care as a distributed system of activities, and (3) to evaluate the scale's psychometric properties. With the theory of distributed cognition as a theoretical underpinning, co-care was operationalized along three dimensions: experience of activities, needs support, and goal orientation. METHODS: Informed by the literature on patient experiences and work psychology, a scale denoted Distribution of Co-Care Activities (DoCCA) was developed with the three conceptualized dimensions, the activities dimension consisting of three sub-factors: demands, unnecessary tasks, and role clarity. It was tested with 113 primary care patients with chronic conditions in Sweden at two time points. RESULTS: A confirmatory factor analysis showed support for a second-order model with the three conceptualized dimensions, with activities further divided into the three sub-factors. Cronbach's alpha values indicated a good to excellent reliability of the subscales, and correlations across time points with panel data indicated satisfactory test-retest reliability. Convergent, concurrent and predictive validity of the scale were, overall, satisfactory. CONCLUSIONS: The psychometric evaluation supports a model consisting of activities (demands, unnecessary tasks, and role clarity), needs support and goal orientation that can be reliably measured with the DoCCA scale. The scale provides a way to assess chronic care management as a system, considering the perspective of the individuals with the chronic condition and how they perceive the work that must be done, across situations, either by themselves or through healthcare, eHealth, or other means.

A typology of useful evidence: approaches to increase the practical value of intervention research.

BACKGROUND: Too often, studies of evidence-based interventions (EBIs) in preventive, community, and health care are not sufficiently useful to end users (typically practitioners, patients, policymakers, or other researchers). The ways in which intervention studies are conventionally conducted and reported mean that there is often a shortage of information when an EBI is used in practice. The paper aims to invite the research community to consider ways to optimize not only the trustworthiness but also the research's usefulness in intervention studies. This is done by proposing a typology that provides some approaches to useful EBIs for intervention researchers. The approaches originate from different research fields and are summarized to highlight their potential benefits from a usefulness perspective. MAIN MESSAGE: The typology consists of research approaches to increase the usefulness of EBIs by improving the reporting of four features in intervention studies: (1) the interventions themselves, including core components and appropriate adaptations; (2) strategies to support-high-quality implementation of the interventions; (3) generalizations about the evidence in a variety of contexts; and (4) outcomes based on end users' preferences and knowledge. The research approaches fall into three levels: Description, Analysis, and Design. The first level, Description, outlines what types of information about the intervention and its implementation, context, and outcomes can be helpful for end users. Research approaches under analysis offers alternative ways of analyzing data, increasing the precision of information provided to end users. Approaches summarized under design involve more radical changes and far-reaching implications for how research can provide more useful information. These approaches partly flip the order of efficacy and effectiveness, focusing not on whether an intervention works in highly controlled and optimal circumstances, but first and foremost whether an intervention can be implemented and lead to anticipated outcomes in everyday practice. CONCLUSIONS: The research community, as well as the end users of research, are invited to consider ways to optimize research's usefulness as well as its trustworthiness. Many of the research approaches in the typology are not new, and their contributions to quality have been described for generations - but their contributions to useful knowledge need more attention.

The Value Equation: Three complementary propositions for reconciling fidelity and adaptation in evidence-based practice implementation.

BACKGROUND: There has long been debate about the balance between fidelity to evidence-based interventions (EBIs) and the need for adaptation for specific contexts or particular patients. The debate is relevant to virtually all clinical areas. This paper synthesises arguments from both fidelity and adaptation perspectives to provide a comprehensive understanding of the challenges involved, and proposes a theoretical and practical approach for how fidelity and adaptation can optimally be managed. DISCUSSION: There are convincing arguments in support of both fidelity and adaptations, representing the perspectives of intervention developers and internal validity on the one hand and users and external validity on the other. Instead of characterizing fidelity and adaptation as mutually exclusive, we propose that they may better be conceptualized as complimentary, representing two synergistic perspectives that can increase the relevance of research, and provide a practical way to approach the goal of optimizing patient outcomes. The theoretical approach proposed, the "Value Equation," provides a method for reconciling the fidelity and adaptation debate by putting it in relation to the value (V) that is produced. The equation involves three terms: intervention (IN), context (C), and implementation strategies (IS). Fidelity and adaptation determine how these terms are balanced and, in turn, the end product - the value it produces for patients, providers, organizations, and systems. The Value Equation summarizes three central propositions: 1) The end product of implementation efforts should emphasize overall value rather than only the intervention effects, 2) implementation strategies can be construed as a method to create fit between EBIs and context, and 3) transparency is vital; not only for the intervention but for all of the four terms of the equation. There are merits to arguments for both fidelity and adaptation. We propose a theoretical approach, a Value Equation, to reconciling the fidelity and adaptation debate. Although there are complexities in the equation and the propositions, we suggest that the Value Equation be used in developing and testing hypotheses that can help implementation science move toward a more granular understanding of the roles of fidelity and adaptation in the implementation process, and ultimately sustainability of practices that provide value to stakeholders.

Building implementation capacity (BIC): a longitudinal mixed methods evaluation of a team intervention.

BACKGROUND: Managers and professionals in health and social care are required to implement evidence-based methods. Despite this, they generally lack training in implementation. In clinical settings, implementation is often a team effort, so it calls for team training. The aim of this study was to evaluate the effects of the Building Implementation Capacity (BIC) intervention that targets teams of professionals, including their managers. METHODS: A non-randomized design was used, with two intervention cases (each consisting of two groups). The longitudinal, mixed-methods evaluation included pre-post and workshop-evaluation questionnaires, and interviews following Kirkpatrick's four-level evaluation framework. The intervention was delivered in five workshops, using a systematic implementation method with exercises and practical working materials. To improve transfer of training, the teams' managers were included. Practical experiences were combined with theoretical knowledge, social interactions, reflections, and peer support. RESULTS: Overall, the participants were satisfied with the intervention (first level), and all groups increased their self-rated implementation knowledge (second level). The qualitative results indicated that most participants applied what they had learned by enacting new implementation behaviors (third level). However, they only partially applied the implementation method, as they did not use the planned systematic approach. A few changes in organizational results occurred (fourth level). CONCLUSIONS: The intervention had positive effects with regard to the first two levels of the evaluation model; that is, the participants were satisfied with the intervention and improved their knowledge and skills. Some positive changes also occurred on the third level (behaviors) and fourth level (organizational results), but these were not as clear as the results for the first two levels. This highlights the fact that further optimization is needed to improve transfer of training when building teams' implementation capacity. In addition to considering the design of such interventions, the organizational context and the participants' characteristics may also need to be considered to maximize the chances that the learned skills will be successfully transferred to behaviors.

Exploring staff experience of economic efficiency requirements in health care: A mixed method study.

BACKGROUND: Economic resources are limited in health care, and governance strategies are used to push provider organizations to use resources efficiently. Although studies show that hybrid managers are successful in reconciling economic efficiency requirements with professional values to meet patient needs, surprisingly few studies focus on staff. The aim of this study is to explore staff members' experience of economic efficiency requirements. METHODS: A mixed method design was applied, targeting multi-professional staff in the Department of Rehabilitation Medicine in a Swedish university hospital. Survey data was collected (n = 93), followed by focus-group interviews to support the understanding of the quantitative findings. FINDINGS: The findings show that health care staff is knowledgeable and intrinsically motivated to consider efficiency requirements, albeit it should not dominate clinical decisions. However, staff experiences little influence over resource allocation and identifies limitations in the system's abilities to meet patient needs. Staff experience incorporates a local unit and a system perspective. CONCLUSION: Staff members are aware of economic efficiency requirements and will behave accordingly if patients are not at risk. However, their engagement seems to rely on how economic efficiency requirements are handled at multiple system levels and their trust in the system to fairly support patient needs.

Colliding ideals - an interview study of how intervention researchers address adherence and adaptations in replication studies.

BACKGROUND: For an intervention to be considered evidence-based, findings need to be replicated. When this is done in new contexts (e.g., a new country), adaptations may be needed. Yet, we know little about how researchers approach this. This study aims to explore how researchers reason about adaptations and adherence when conducting replication studies, describe what adaptations they make and how these are reported in scientific journals. METHODS: This was an interview study conducted in 2014 with principal investigators of Swedish replication studies reporting adaptations to an intervention from another country. Studies (n = 36) were identified through a database of 139 Swedish psychosocial and psychological intervention studies. Twenty of the 21 principal investigators agreed to participate in semi-structured telephone interviews, covering 33 interventions. Manifest content analysis was used to identify types of adaptations, and qualitative content analysis was used to explore reasoning and reporting of adaptations and adherence. RESULTS: The most common adaptation was adding components and modifying the content to the target population and setting. When reasoning about adaptations and adherence, the researchers were influenced by four main factors: whether their implicit aim was to replicate or improve an intervention; the nature of evidence outlying the intervention such as manuals, theories and core components; the nature of the context, including approaches to cultural adaptations and constraints in delivering the intervention; and the needs of clients and professionals. Reporting of adaptations in scientific journals involved a conflict between transparency and practical concerns such as word count. CONCLUSIONS: Researchers responsible for replicating interventions in a new country face colliding ideals when trying to protect the internal validity of the study while considering adaptations to ensure that the intervention fits into the context. Implicit assumptions about the role of replication seemed to influence how this conflict was resolved. Some emphasised direct replications as central in the knowledge accumulation process (stressing adherence). Others assumed that interventions generally need to be improved, giving room for adaptations and reflecting an incremental approach to knowledge accumulation. This has implications for design and reporting of intervention studies as well as for how findings across studies are synthesised.

The development and validation of a scale to explore staff experience of governance of economic efficiency and quality (GOV-EQ) of health care.

BACKGROUND: In publicly funded health care systems, governance models are developed to push public service providers to use tax payers' money more efficiently and maintain a high quality of service. Although this implies change in staff behaviors, evaluation studies commonly focus on organizational outputs. Unintended consequences for staff have been observed in case studies, but theoretical and methodological development is necessary to enable studies of staff experience in larger populations across various settings. The aim of the study is to develop a self-assessment scale of staff experience of the governance of economic efficiency and quality of health care and to assess its psychometric properties. METHODS: Factors relevant to staff members' experience of economic efficiency and quality requirements of health care were identified in the literature and through interviews with practitioners, and then compared to a theoretical model of behavior change. Relevant experiences were developed into sub-factors and items. The scale was tested in collaboration with the Department of Rehabilitation Medicine at a university hospital. 93 staff members participated. The scale's psychometric properties were assessed using exploratory factor analysis, analysis of internal consistency and criterion-related validity. RESULTS: The analysis revealed an eight factor structure (including sub-factors knowledge and awareness, opportunity to influence, motivation, impact on professional autonomy and organizational alignment), and items showed strong factor loadings and high internal consistency within sub-factors. Sub-factors were interrelated and contributed to the prediction of impact on clinical behavior (criterion). CONCLUSIONS: The scale clearly distinguishes between various experiences regarding economic efficiency and quality requirements among health care staff, and shows satisfactory psychometric quality. The scale has broad applications for research and practice, as it serves as a tool for capturing staff members' perspectives when evaluating and improving health care governance. The scale could also be useful for understanding the underlying processes of changes in provider performance and for adapting management strategies to engage staff in driving change that contributes to increased economic efficiency and quality, for the benefit of health care systems, patients and staff.

Using kaizen to improve employee well-being: Results from two organizational intervention studies.

Participatory intervention approaches that are embedded in existing organizational structures may improve the efficiency and effectiveness of organizational interventions, but concrete tools are lacking. In the present article, we use a realist evaluation approach to explore the role of kaizen, a lean tool for participatory continuous improvement, in improving employee well-being in two cluster-randomized, controlled participatory intervention studies. Case 1 is from the Danish Postal Service, where kaizen boards were used to implement action plans. The results of multi-group structural equation modeling showed that kaizen served as a mechanism that increased the level of awareness of and capacity to manage psychosocial issues, which, in turn, predicted increased job satisfaction and mental health. Case 2 is from a regional hospital in Sweden that integrated occupational health processes with a pre-existing kaizen system. Multi-group structural equation modeling revealed that, in the intervention group, kaizen work predicted better integration of organizational and employee objectives after 12 months, which, in turn, predicted increased job satisfaction and decreased discomfort at 24 months. The findings suggest that participatory and structured problem-solving approaches that are familiar and visual to employees can facilitate organizational interventions.

Novel Programs, International Adoptions, or Contextual Adaptations? Meta-Analytical Results From German and Swedish Intervention Research.

One of the major dilemmas in intervention and implementation research is adaptation versus adherence. High fidelity to an intervention protocol is essential for internal validity. At the same time, it has been argued that adaptation is necessary for improving the adoption and use of interventions by, for example, improving the match between an intervention and its cultural context, thus improving external validity. This study explores the origins of intervention programs (i.e., novel programs, programs adopted from other contexts with or without adaptation) in two meta-analytic intervention data sets from two European countries and compares the effect sizes of the outcomes of the interventions evaluated. Results are based on two samples of studies evaluating German child and youth preventative interventions (k = 158), and Swedish evaluations of a variety of psychological and social interventions (k = 139). The studies were categorized as novel programs, international adoption and contextual adaptation, with a total of six subcategories. In the German sample, after statistically controlling for some crucial methodological aspects, novel programs were significantly more effective than adopted programs. In the Swedish sample, a trend was found suggesting that adopted programs were less effective than adapted and novel programs. If these results are generalizable and unbiased, they favor novel and adapted programs over adopted programs with no adaptation and indicate that adoption of transported programs should not be done without considering adaptation.

Integrating health promotion with quality improvement in a Swedish hospital.

Integration of workplace employee health promotion (HP) and occupational health and safety (OHS) work into organizational quality improvement systems is suggested as a way to strengthen HP and OHS activities in an organization. The aim of this article was to study what consequences integration of HP, OHS and a quality improvement system called kaizen has on the frequency and type of HP and OHS activities. A quasi-experimental study design was used where an integration of the three systems for HP, OHS respectively kaizen, was performed at six intervention units at a Swedish hospital. The remaining six units served as controls. Document analysis of all employees' written improvement suggestions (kaizen notes) during 2013 was conducted. The findings show that the intervention group had more suggestions concerning HP and OHS (n = 114) when compared with the control group (n = 78) and a greater variety of HP and OHS suggestions. In addition, only the intervention group had included HP aspects. In both groups, most kaizen notes with health consideration had a preventive focus rather than rehabilitative. The intervention, i.e. the integration of HP, OHS and kaizen work, had a favourable effect on HP and OHS work when compared with the controls. The results of the study support that this system can work in practice at hospitals.

Investigating variations in implementation fidelity of an organizational-level occupational health intervention.

BACKGROUND: The workplace has been suggested as an important arena for health promotion, but little is known about how the organizational setting influences the implementation of interventions. PURPOSE: The aims of this study are to evaluate implementation fidelity in an organizational-level occupational health intervention and to investigate possible explanations for variations in fidelity between intervention units. METHOD: The intervention consisted of an integration of health promotion, occupational health and safety, and a system for continuous improvements (Kaizen) and was conducted in a quasi-experimental design at a Swedish hospital. Implementation fidelity was evaluated with the Conceptual Framework for Implementation Fidelity and implementation factors used to investigate variations in fidelity with the Framework for Evaluating Organizational-level Interventions. A multi-method approach including interviews, Kaizen notes, and questionnaires was applied. RESULTS: Implementation fidelity differed between units even though the intervention was introduced and supported in the same way. Important differences in all elements proposed in the model for evaluating organizational-level interventions, i.e., context, intervention, and mental models, were found to explain the differences in fidelity. CONCLUSION: Implementation strategies may need to be adapted depending on the local context. Implementation fidelity, as well as pre-intervention implementation elements, is likely to affect the implementation success and needs to be assessed in intervention research. The high variation in fidelity across the units indicates the need for adjustments to the type of designs used to assess the effects of interventions. Thus, rather than using designs that aim to control variation, it may be necessary to use those that aim at exploring and explaining variation, such as adapted study designs.

Interactions between lean management and the psychosocial work environment in a hospital setting - a multi-method study.

BACKGROUND: As health care struggles to meet increasing demands with limited resources, Lean has become a popular management approach. It has mainly been studied in relation to health care performance. The empirical evidence as to how Lean affects the psychosocial work environment has been contradictory. This study aims to study the interaction between Lean and the psychosocial work environment using a comprehensive model that takes Lean implementation information, as well as Lean theory and the particular context into consideration. METHODS: The psychosocial work environment was measured twice with the Copenhagen Psychosocial Questionnaire (COPSOQ) employee survey during Lean implementations on May-June 2010 (T1) (n = 129) and November-December 2011 (T2) (n = 131) at three units (an Emergency Department (ED), Ward-I and Ward-II). Information based on qualitative data analysis of the Lean implementations and context from a previous paper was used to predict expected change patterns in the psychosocial work environment from T1 to T2 and subsequently compared with COPSOQ-data through linear regression analysis. RESULTS: Between T1 and T2, qualitative information showed a well-organized and steady Lean implementation on Ward-I with active employee participation, a partial Lean implementation on Ward-II with employees not seeing a clear need for such an intervention, and deterioration in already implemented Lean activities at ED, due to the declining interest of top management. Quantitative data analysis showed a significant relation between the expected and actual results regarding changes in the psychosocial work environment. Ward-I showed major improvements especially related to job control and social support, ED showed a major decline with some exceptions while Ward-II also showed improvements similar to Ward-I. CONCLUSIONS: The results suggest that Lean may have a positive impact on the psychosocial work environment given that it is properly implemented. Also, the psychosocial work environment may even deteriorate if Lean work deteriorates after implementation. Employee managers and researchers should note the importance of employee involvement in the change process. Employee involvement may minimize the intervention's harmful effects on psychosocial work factors. We also found that a multi-method may be suitable for investigating relations between Lean and the psychosocial work environment.

Functions of behavior change interventions when implementing multi-professional teamwork at an emergency department: a comparative case study.

BACKGROUND: While there is strong support for the benefits of working in multi-professional teams in health care, the implementation of multi-professional teamwork is reported to be complex and challenging. Implementation strategies combining multiple behavior change interventions are recommended, but the understanding of how and why the behavior change interventions influence staff behavior is limited. There is a lack of studies focusing on the functions of different behavior change interventions and the mechanisms driving behavior change. In this study, applied behavior analysis is used to analyze the function and impact of different behavior change interventions when implementing multi-professional teamwork. METHODS: A comparative case study design was applied. Two sections of an emergency department implemented multi-professional teamwork involving changes in work processes, aimed at increasing inter-professional collaboration. Behavior change interventions and staff behavior change were studied using observations, interviews and document analysis. Using a hybrid thematic analysis, the behavior change interventions were categorized according to the DCOM® model. The functions of the behavior change interventions were then analyzed using applied behavior analysis. RESULTS: The two sections used different behavior change interventions, resulting in a large difference in the degree of staff behavior change. The successful section enabled staff performance of teamwork behaviors with a strategy based on ongoing problem-solving and frequent clarification of directions. Managerial feedback initially played an important role in motivating teamwork behaviors. Gradually, as staff started to experience positive outcomes of the intervention, motivation for teamwork behaviors was replaced by positive task-generated feedback. CONCLUSIONS: The functional perspective of applied behavior analysis offers insight into the behavioral mechanisms that describe how and why behavior change interventions influence staff behavior. The analysis demonstrates how enabling behavior change interventions, managerial feedback and task-related feedback interact in their influence on behavior and have complementary functions during different stages of implementation.

Leader personality and 360-degree assessments of leader behavior.

To investigate the relationship between personality and multi-source feedback, we assessed 190 health care managers by applying the Understanding Personal Potential personality test, which provides comprehensive measurement of the Big Five dimensions and eight narrower personality traits. Managers' leadership behaviors were assessed by colleagues, supervisors, a random sample of each manager's subordinates as well as the managers themselves using a 360-degree change, production, employee (CPE) instrument. Hierarchical multivariate regression analysis showed that the Big Five variables were significantly related to the Managers' leadership behavior in all CPE dimensions. Also, addition of narrow personality variables to the Big Five increased explained variance in leadership behavior. This study is the first of its kind to include the full range of viewpoints in a 360-degree instrument, along with a large number of subordinate assessments. We found that both the strength of the relationship between personality and behavior and the configuration of different predictors varied depending on who did the rating and what leadership orientation was investigated, and this observation merits further investigation.

Fidelity-consistency and deliberateness of modifications in parenting programs.

BACKGROUND: Evidence-based interventions (EBIs) are frequently modified in practice. It is recommended that decisions to modify EBIs should be made deliberately to ensure fidelity-consistency, yet the relationship between fidelity-consistency and deliberateness is not well understood. This study aims to explore modifications in a sample of practitioners delivering evidence-based parenting programs (i.e., interventions to strengthen parent-child relationships, reduce harmful interactions, and improve child health and well-being). The study investigated three research questions: (1) What kind of modifications are made during the delivery of parenting programs? (2) To what degree are the identified modifications consistent with the core functions of each program? and (3) Is deliberateness associated with the fidelity-consistency of the identified modifications? METHODS: In total, 28 group leaders of five widely disseminated parenting programs in Sweden participated in five focus groups, and two participants from each group also participated in individual interviews (n = 10). A content analysis approach was used where the identification of modifications was directed by the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) and then assessed for fidelity-consistency and four levels of deliberateness (universal, situational, conditional, and unintentional). Chi-square tests were performed to compare consistent and inconsistent modifications, and logistic regression was performed to explore whether deliberateness predicted consistency. RESULTS: A total of 137 content modifications were identified, covering most of the content modification categories in FRAME. The most common were tailoring/tweaking/refining, adding elements, shortening/condensing, lengthening/extending, and integrating another treatment. Modifications were mostly fidelity-consistent but consistency varied greatly among categories. Furthermore, modifications made unintentionally or situationally were more likely to be fidelity-inconsistent. CONCLUSIONS: These results indicate that explicit consideration of modifications and their impact could be essential for sustaining the fidelity-consistent use of EBIs, even as such interventions are continuously modified.

Strategies to reduce low-value care - An applied behavior analysis using a single-case design.

Introduction: Implementation science has traditionally focused on the implementation of evidence-based practices, but the field has increasingly recognized the importance of addressing de-implementation (i.e., the process of reducing low-value care). Most studies on de-implementation strategies have used a combination of strategies without addressing factors that sustain the use of LVC and there is a lack of information about which strategies are most effective and what mechanisms of change might underlie these strategies. Applied behavior analysis is an approach that could be a potential method to gain insights into the mechanisms of de-implementation strategies to reduce LVC. Three research questions are addressed in this study: What contingencies (three-term contingencies or rule-governing behavior) related to the use of LVC can be found in a local context and what strategies can be developed based on an analysis of these contingencies?; Do these strategies change targeted behaviors?; How do the participants describe the strategies' contingencies and the feasibility of the applied behavior analysis approach? Materials and methods: In this study, we used applied behavior analysis to analyze contingencies that maintain behaviors related to a chosen LVC, the unnecessary use of x-rays for knee arthrosis within a primary care center. Based on this analysis, strategies were developed and evaluated using a single-case design and a qualitative analysis of interview data. Results: Two strategies were developed: a lecture and feedback meetings. The results from the single-case data were inconclusive but some of the findings may indicate a behavior change in the expected direction. Such a conclusion is supported by interview data showing that participants perceived an effect in response to both strategies. Conclusion: The findings illustrate how applied behavior analysis can be used to analyze contingencies related to the use of LVC and to design strategies for de-implementation. It also shows an effect of the targeted behaviors even though the quantitative results are inconclusive. The strategies used in this study could be further improved to target the contingencies better by structuring the feedback meetings better and including more precise feedback.

Job crafting interventions: what works, for whom, why, and in which contexts? Research protocol for a systematic review with coincidence analysis.

BACKGROUND: Recent challenges in the working world that resulted from the pandemic and technological advances have underlined the importance of flexibility in how jobs are designed. Job crafting (JC) refers to self-initiated changes that employees introduce to their jobs to optimize their job design and increase the fit between the job and their needs and preferences. These behaviors can be stimulated by job crafting training interventions, which aim to change how individual employees design, organize, or manage their work. However, since the interventions are implemented in various ways, we do not know which context and intervention factors are necessary or sufficient to achieve desired outcomes. Without this knowledge, benefitting from the potential of job crafting interventions is limited. The overall aim of this project will be to investigate what combinations of context, intervention, and mechanism factors are linked with effective JC interventions. Specifically, we will detect what factors are minimally sufficient and/or necessary to produce a successful JC intervention, how they combine, as well as what are the multiple alternative paths to their success. METHODS: We will perform a systematic review of the JC interventions literature combined with coincidence analysis (CNA). We will search electronic databases of journals and utilize Rayyan software to make decisions regarding inclusion. Data regarding context (e.g., fit), intervention (e.g., types of activities), mechanisms (e.g., intention implementation), and outcomes (e.g., employee well-being, job performance) will be extracted using a pre-piloted form and coded into a crisp-set (factor present vs. absent). Analyses will be carried out using the CNA package in R. DISCUSSION: This review will address gaps in knowledge about the context, intervention, and mechanism-related factors that may impact the effects of JC interventions. Consequently, this review will help develop a program theory for JC interventions that explains what works, how and under which circumstances. Applying CNA to synthesize these complex solutions across multiple studies provides an innovative method that may be used in future review attempts evaluating the implementation of interventions. Finally, our synthesis will provide knowledge relevant to organizational practitioners and scholars who want to implement JC interventions. TRIAL REGISTRATION: https://osf.io/2g6yx.