Main themes emerged on “how to” undertake pragmatic implementation in a complex healthcare setting across:
Table 2 outlines the main themes and sub-themes and the inter-related dynamism across these. The team displayed leadership qualities of agency and collaboration engaging clinicians as they navigated a shifting and complex context, while applying scientific thinking with pragmatic, responsive and iterative action. Table 3. Provides example quotes where each theme is discussed and demonstrated.
Table 2
Thematic Analysis and main themes.
Main Themes
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Leadership
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Processes applied
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Navigating Context
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Sub-themes
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· Agency
· Capability for engagement
· Teamwork and collaborative approaches
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· Focus on patient need
· Planning, execution, evaluation
- Designed for sustainability and scale-up
- Theory driven improvement and implementation
- Iterative
· Project management
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‘Bottom-up’ approach
- Embedded at the point of change
- Co-designed
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Main Theme – Leadership: Characteristics of the implementation team leading and engaging with target clinicians with improvement work
This main theme and sub-themes captured the implementation team’s demonstration of diplomacy and communication required for interaction and engagement with those involved in healthcare improvement. The sub-themes included agency, capability and teamwork.
Agency
Agency is the capacity to act with purpose, power and courage to initiate improvement in response to gaps or suboptimal quality of care.[19] Agency was exhibited in response to patient need, reinforced by national guidelines. The implementation team recognised the relevance and importance of aligning internal organisational strategic directions and external levers, such as national guidelines. The team utilised this structural lever to initiate dialogue with stakeholders, who brought added expertise to the improvement work from within the health service and externally. It galvanised the belief in the work and the desire to improve with clear the rationale for immediate action from stakeholders, fellow clinicians, health service personnel and organisational leaders, as champions. The team identified and engaged with others with additional expertise and a shared vision. The implementation team’s actions revealed passion, competence and expertise, with confidence to act and lead. As leaders of change with agency to drive the work, the team recognised and leveraged their expertise, position and role. This was a significant characteristic, consistently displayed throughout the work and with all stakeholders.
Capability for engagement
Diplomacy, or high-level communication skills were applied to achieve engagement and negotiation with change participants or adopters. The team worked hard to connect, understand and engage with clinicians around the new practice considering context and barriers and enablers of the intervention and its implementation. They adopted collaborative, shared leadership, to adapt, modify and shape the process, according to contextual issues, such as time limits, patient needs, or information technology capacities. The team consistently inspired others using strong communication skills, emotional intelligence and diplomacy skills, tacitly demonstrated and explicitly described by the team. Tacit characteristics included non-cognitive, personal traits to engage with frontline clinician adopters, to gauge their reactions and to respond to unspoken messaging within particular circumstances. This quality reflected personal motivations of the implementers and the leveraging of a shared motivation with adopters to achieve “best practice” for patient care.
Teamwork and collaboration
Teamwork was a dominant characteristic and was connected to aspects of networking, negotiating, relationship-building and connection development. In terms of explicit characteristics, strong teamwork principles of collaboration and co-design were applied including frontline managers and clinical teams (target clinicians). Implementers worked hard to build connections and relationships between adopters and improvement work, including intervention co-development and refinement. Communication and connection-building served to foster trust and enhance relevance of the improvement work with adopters. The team communicated consistently and frequently with all stakeholders.
Collaborative approaches included problem-solving, where no problem was too insignificant or to intractable. Frontline teamwork was demonstrated through consistent stakeholder engagement and on-ground coaching, with high levels of communication with frontline staff and recognition of on-ground problems and progress.
Main Theme - Process of improvement and implementation
This theme highlights key motivations for the improvement work and the structural and practical elements of implementation team action. It includes team processes utilised, and actions taken to progress the work. Sub-themes included the focus on patient need as a key motivator for clinicians and the planning, execution and evaluation of the implementation process. Other sub-themes involved intervention development, theory-driven implementation processes, consideration of sustainability and scale up issues, analysis of implementation barriers, enablers, and measurement and use of process and outcome evaluation.
Method of improvement and change process (planning, execution and evaluation)
Key activities included planning, execution and evaluation, captured across data sources. Figure 1 illustrates the implementation process. The aim to integrate routine mental health screening into antenatal care for a vulnerable population of refugee women and link them with a pathway to community care, was driven by a national guideline[20] combined with an external screening tool. The case was a hybrid of an implementation research project, but was strongly focused on sustainability and scalability, once proven effective. This team applied an established implementation theoretical framework (the Normalization Process Theory)[21] that underpinned evaluation and measurement of practice change and health outcomes.
The case included an in-depth assessment of patient needs and clinician perspectives to inform the co-designed improvement process. The team reported (and published) extensive communication with multiple stakeholders internally and externally to the health service, before and during the implementation. Specifically, barriers and enablers to implementing evidence-based, nationally recommended screening were explored to inform sustainability of a screening and referral programme in the planning phase. Iterative co-design with target clinicians, clinical leaders, technology experts and academics occurred throughout. Modifications and solution development occurred more intensely at the beginning and less so over the implementation. Coaching with target clinicians was also intense at the beginning to ensure feasibility and practical use of the newly implemented assessment tool. While the tool was designed for sustainability and spread, it deviated from usual practice. To this end, sustainability was considered and planned from the outset, but strategies were only instigated after evaluation indicated efficacy. Several implementation team members indicated, “If we can get it right in this setting [refugee, maternal health services], it should be easier to establish it in a less challenging general maternity setting”.
A prevailing observation was the unremitting effort and the availability of the project officer and clinical leaders (both part of the team) for clinicians adopting new practices and tools. All team members, particularly the project officer, were readily available to observe, coach and engage frontline target clinicians as well as acting as liaison between these clinicians and the implementation team.
The recognition of patient need was demonstrated through the clear commitment to ensuring this worked for the target clinicians and of prime importance, for the refugee women. Considerable effort was committed to developing and refining the screening tool to ensure it was understood by the women, across terminology, cultural appropriateness and translation into different languages.
Project management
Project management was an important role for the improvement/change facilitator, who was also a coach and PhD Scholar, with a background as a midwife and maternal child health clinician. Tasks involved organising meetings, progressing the project and reporting updates on all aspects of project progress. This was a regular and ongoing task to articulate and investigate problems and trouble-shoot and resolve situations that reconciled both research purposes with pragmatic actions.
Main theme - Navigating context
This theme captured diverse aspects of the case study context and how the implementation team navigated this. Sub-themes included project governance at a local and organisational level, and the team positioning, allowing multi-disciplinary capability, to respond to a changing complex environment, adjusting iteratively.
Governance
Although governance represented a ‘bottom-up’ approach informed by implementation research, co-design and a collaborative approach to improvement, leadership and support ‘on the ground’ came from local leaders directly involved in service delivery with the identified vulnerable population and improvement setting. The senior clinical lead in the implementation team engaged with progress and problems with the Department head and manager, to secure ongoing support including for sustainable implementation.
Team members had roles that straddled an integrated Research Translation Centre or “implementation laboratory”, firmly established as a partnership across the university and health service. The team were also largely clinicians and central stakeholders in the health service and improvement process. This leveraged the onsite partnership between the Research Centre and the health service. Team members often wore two hats, as implementers and clinician leaders. This research lens and expertise facilitated insightful perspectives about the improvement process, balanced with practical implementation ‘at the coalface’. Additional academic funding was attracted to support the project, while senior researchers undertook the work as part of their academic roles. The clinician leaders in the implementation team also undertook the work as part of their role in delivering high quality care.
Table 3
Exemplar responses illustrating the major themes: Leadership; Process; Context
Leadership and engagement
I think having champions is really useful, so having people who are - and they have to be the right people, because it’s not necessarily going to be the senior leader, it’s someone who is respected within the space, who people listen to, who isn’t necessarily the named leader - and engaging them in a meaningful way and then getting them to lead the change. So I don’t think we necessarily need the senior leaders or the whole units at the table, but we need selected important people to be engaged and be able to be seen to be engaged so that they can take it forward.
But I think we do need everyone, and I think there are so many units that if we don’t give the opportunity, at least, for each of them to be engaged then they can be lost. If it’s just engaged at a program level there are an awful lot of people who sit under the same banner and have really, really diverse practices and workforce and everything else, so being able to have representation from areas is, I think, going to be important at the outset, rather than just bringing them in once it’s been decided.
Senior Medical Lead
I think it’s a very collaborative process, because...Mostly people aren’t, people are pretty happy to work you know and I think there may be times in the future where for example, [X] and [Y] are interested in following up some of the children and I would be happy to hand that over, that’s their areas of expertise and I don't think, I think we all recognise each other’s area and we are all building to each other's strengths. And so far there hasn’t really been any competiveness.
Clinical Lead and senior academic
We spoke to settlement services, community members, the managers and staff I worked with at the community health centre, because you want to look at where you’re going to get your referrals from. People need to know about the service, they need to know what’s happening and how it’s going to be implemented. Feel that they’re actually a part of the process, not just left out - through meetings, chatting. I think essentially I feel I’m a good networker, and I think that’s something that - when I think back to that work we did in the refugee work and this as well, I’ve also been really fortunate, I’ve worked in [X health service] for 30 years so I know a lot of people, the midwifery staff know me, I know them. I’ve worked with a lot of them. So all those things have helped a lot too. And because, in the sense I’m one of them, that’s probably helped.
Project Officer
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Process of improvement and implementation
Before we even did the formative research, the important thing was we knew we needed to speak to community members
Senior Research Fellow (Psychology)
The main driver was that it was a very high risk population and we were concerned about that gap and care for them. So as we went through we started talking to more and more people, we met more people. And then we met the CEO from a not for profit non-government organisation that has funding to provide to try and introduce screening in pregnancy for anxiety and depression and they already had – so they had tools and resources and experience that we could leverage off.
Senior Research Fellow (Health service research)
I contacted the maternity services, found out why they weren’t doing it. Looked at what could we do that would enable us to try it and then the important thing for us was you know, before we even did the formative research, the important thing was we knew we needed to speak to community members. Because a lot of people anecdotally have always said that you can’t scene with cultural and linguistically diverse women or women from those backgrounds. Because the screening tool doesn’t work with them, because they have different concepts of mental health and therefore they won’t want to engage with it. But that wasn’t the message and that’s why we really made an effort too.
Implementation team member
The national guidelines are for every woman. We decided to start with refugee women, acknowledging that it was a high risk population and yep, probably where the greatest unmet need was. Of course it was also the most complex population which is one of the reasons why it hasn't been done. And there was a little bit of an attitude of well if we can make it work in this population we can probably make it work in the general population. So the chances of being able to roll it out across all of the Maternity Service would be great if we could get it to work in this most challenging circumstance. If we can demonstrate that it works in this situation then there can be very little criticism or very little but what if? There are very few excuses that can come up that we have not already seen and addressed.
Senior Research Fellow (Health service research)
We need to prove the effectiveness of the assessment tool, before we set about sustaining it in practice. If it wasn’t effective at achieving the set objective then we would not want to sustain it.
Senior Research Fellow
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Context
We’ve received funding from [X health service] and [X university] and from [X research translation centre] as well. And the leverage that then gives us is that if we experience really serious barriers we can go to very high levels at those organisations who hold quite a lot of power and say, “Look, you and these other organisations have invested considerably in this project, recognising that it is a key priority for you, and we are experiencing these problems that we haven't been able to address ourselves and we need some high level support on it.” And we've not had to use that because it's quite a blunt instrument. Yeah we haven't had to really call that into use yet but it's nice to have that strategic high level support.
Senior Academic Lead
I can't speak highly enough of the people above me. I think that they really are cognisant of the impact of perinatal mental health on women and newborn well-being, and they've been very keen to explore opportunities to do things differently or to do some short sharp, change management as an intervention that might make a difference to the outcomes that we're getting. Yeah, so certainly at the levels that I've been, they've been very engaged and very curious about what we can do and have been more than supportive.
Midwife - Nurse manager
But it’s got to the point where a lot of the hard work has been done. But I think some of that has been because I’ve been quite strategic. I’ve been around long enough to know that research is something that buys you credibility in academic environments. And to be strategically aligned with projects like this, or other projects, buys me credibility, in terms of, you know having bargaining power and having some influence, I suppose.
Service manager
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Mapping our themes with CFIR
To enhance understanding of the “how to” issues of pragmatic implementation and improvement in complex healthcare settings, themes were mapped to the CFIR. Our complex healthcare improvement case study, applied the CFIR lens to real-world longitudinal ethnographic research, could be integrated with IS. We also aimed to bring further depth to the IS and HCI.
The mapping involved aligning our themes (critical features of improvement work as explained earlier), and an in-depth examination of the CFIR domains and constructs definitions to uncover similarities and differences. Here we also explored and illustrated the complex interplay of factors operating in healthcare improvement work, highlighting the relationships between the constructs, and presenting a complex nuanced assessment of the people, contexts and process that underpin and confront change at the clinical frontline.
The mapping process demonstrated alignment between our themes and the CFIR components, as presented in Table 4, showing overlap across the Outer and Inner settings and Process domains and constructs. This is unsurprising given our research focus was on the work of implementation teams and these CFIR domains reflect much of the contextual and process aspects that impact implementation work.
The mapping process also highlighted variation including the implementation team’s leadership approaches, persistent and iterative along with collaborative engagement with stakeholders, especially target clinicians at the coalface throughout the improvement work. The implementation team navigated and embraced the complex and dynamic contextual circumstances, as well as the intervention and implementation process itself. The research reflected an inter-related nature of the themes and the dynamic aspects of the improvement work. Born out in our leadership theme we observed an element that was cross-cutting and permeated all of our other themes (process and context), as well as, all aspects of the CFIR, through agency, engagement and skills. In particular, all aspects of CFIR Outer setting (B. Cosmopolitanism), Inner setting (Networks and Communications) and Process (B. Engaging) mapped to our leadership theme (Table 4). In this distributed leadership model of our case study, no one person held all responsibility and the team collaborated including individual capabilities and responsibilities and when appropriate, they led the work by engaging others and navigating context. This provides insights into a leadership model that appears to enhance implementation success.
Table 4
Mapping of themes with CFIR constructs and domains
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CFIR Constructs
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Our themes
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Outer setting
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Inner setting
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Characteristics of individuals*
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Intervention characteristics
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Process
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Leadership
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B. Cosmopolitanism
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B. Networks and Communications
E. Readiness for Implementation-
E1. Leadership Engagement
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B. Engaging
B1. Opinion Leaders
B2. Formally Appointed Internal Implementation leaders
B3. Champions
B4. External Change Agents
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Context
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A. Patient needs & resources
B. Cosmopolitanism
D. External Policies & Incentives
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B. Networks and Communications
D. Implementation Climate
· D3. Relative priority
E. Readiness for Implementation
· E1. Leadership Engagement
· E2. Available Resources
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A. Knowledge and Beliefs
B. Self-efficacy
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Process
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A. Patient needs & resources
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D. Implementation Climate
· D4. Organisational Incentive and rewards:
· D5. Goals and Feedback
· D6. Learning Climate.
E. Readiness for implementation:
· E3. Access to information and knowledge
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C. Relative advantage
D. Adaptability
F. Complexity
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A. Planning
C. Executing
D. Reflecting and Evaluating
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* Characteristics of individuals not directly observed by the researchers, but discussed by the implementation team and observed in their actions toward/with the target clinicians.
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