Table 1 displays the content, duration, and disciplines involved in each interview and focus group. Five focus groups and six interviews with 21 HCPs from different disciplines, and one focus group with six patients were held. The results were analysed and described, based on the domains of the CFIR (Fig 2).
Table 1: Description of the content, duration, and discipline involved for the focus groups and interviews
|
Phase 1
|
Phase 2
|
Phase 3
|
FG 1
|
FG 2
|
INT 1
|
INT2
|
INT 3
|
INT 4
|
FG 3
|
FG 4
|
INT 5
|
INT 6
|
FG 5
|
FG 6
|
Duration
|
1h45m
|
1h26m
|
37m
|
36m
|
29m
|
28 m
|
1h35m
|
1h24m
|
27m
|
49m
|
1h34m
|
1h48m
|
Goal
|
|
|
|
|
|
|
|
|
|
|
|
|
Experiences with the organization of rehabilitation care for patients with CMP before participating in NPRL
|
|
|
x
|
x
|
x
|
x
|
|
x
|
x
|
x
|
|
|
Expectations for participation in NPRL
|
x
|
x
|
x
|
x
|
x
|
x
|
|
|
|
x
|
|
|
Barriers and facilitators of the development process
|
x
|
x
|
|
|
|
|
|
x
|
x
|
|
|
|
Barriers and facilitators of the implementation strategy
|
|
|
|
|
|
|
x
|
|
x
|
|
x
|
|
Expected barriers and facilitators of the transferability phase
|
|
|
|
|
|
|
|
|
|
|
x
|
|
Current experiences being a patient in NPRL (eg. eHealth, healthcare professional skills, referral, treatment, feeling of collaboration)
|
|
|
|
|
|
|
|
|
|
|
|
x
|
|
Discipline
|
Gender
|
Exp. (yrs)
|
|
P1
|
PT
|
F
|
2.5
|
x
|
|
|
|
|
|
x
|
|
|
|
|
|
P2
|
PT
|
M
|
0.5
|
x
|
|
|
|
|
|
|
|
|
|
x
|
|
P3
|
PT
|
M
|
34
|
x
|
|
|
|
|
|
x
|
|
|
|
|
|
P4
|
PT
|
M
|
38
|
x
|
|
|
|
|
|
|
|
|
|
|
|
P5
|
PT
|
F
|
7
|
|
x
|
|
|
|
|
x
|
|
|
|
|
|
P6
|
PT
|
M
|
30
|
|
x
|
|
|
|
|
|
|
|
|
|
|
P7
|
PT
|
M
|
33
|
|
x
|
|
|
|
|
|
|
|
|
|
|
P8
|
ET
|
F
|
25
|
|
x
|
|
|
|
|
x
|
|
|
|
|
|
P9
|
PNMH
|
F
|
-
|
|
|
|
|
|
|
|
|
x
|
|
|
|
P10
|
GP
|
M
|
10
|
x
|
|
|
|
|
|
x
|
|
|
|
|
|
P11
|
GP
|
M
|
31
|
x
|
|
|
|
|
|
|
|
|
|
|
|
P12
|
GP
|
M
|
8
|
|
x
|
|
|
|
|
|
|
|
|
x
|
|
P13
|
PSY-2
|
F
|
-
|
|
|
|
|
x
|
|
|
|
|
|
|
|
P14
|
RP-2
|
F
|
6
|
|
|
|
|
|
x
|
|
x
|
|
|
|
|
P15
|
RP-2
|
M
|
-
|
|
|
|
|
|
|
|
x
|
|
|
x
|
|
P16
|
RP-3
|
F
|
-
|
|
|
x
|
|
|
|
|
|
|
|
|
|
P17
|
RP-3
|
F
|
<1
|
|
|
|
x
|
|
|
|
|
|
|
|
|
P18
|
PA-3
|
M
|
15
|
|
|
|
|
|
|
|
x
|
|
|
x
|
|
P19
|
NP-3
|
F
|
6
|
|
|
|
|
|
|
|
x
|
|
|
x
|
|
P20
|
TC-3
|
F
|
-
|
|
|
|
|
|
|
|
|
|
|
x
|
|
P21
|
RP-2
|
M
|
-
|
|
|
|
|
|
|
|
|
|
x
|
|
|
P30
|
PNT
|
F
|
n.a
|
|
|
|
|
|
|
|
|
|
|
|
x
|
P31
|
PNT
|
F
|
n.a
|
|
|
|
|
|
|
|
|
|
|
|
x
|
P32
|
PNT
|
F
|
n.a
|
|
|
|
|
|
|
|
|
|
|
|
x
|
P33
|
PNT
|
M
|
n.a
|
|
|
|
|
|
|
|
|
|
|
|
x
|
P34
|
PNT
|
F
|
n.a
|
|
|
|
|
|
|
|
|
|
|
|
x
|
P35
|
PNT
|
M
|
n.a
|
|
|
|
|
|
|
|
|
|
|
|
x
|
FG: focus group; INT: interview; EXP: years experience; PT: physiotherapist; ET: exercise therapist; PNMH; practice nurse mental health; GP: general practitioner; PSY-2: psychologist secondary care; RP-2: rehabilitation physician secondary care; RP-3: rehabilitation physician tertiary care; PA-3: physician assistant tertiary care; NP-3: nurse practitioner tertiary care; TC-3: treatment coach tertiary care; PNT: patient; F: female; M: male; -: unknown; n.a.: not applicable
|
Intervention
Assessment Tool 1 & Assessment Tool 2
HCPs in primary care found Assessment Tool 1 too time-consuming, because of the extra burden for the patient and the extra time for the consultation itself. A further consultation to discuss the results with patients was not desirable. “I have no time to discuss the results with the patient in an extra consultation.” (P12: GP, FG2). In addition, several HCPs thought that the results of Assessment Tool 1 were not in line with their conclusions, based on their observations, experience, and assessments of patients. All secondary and tertiary rehabilitation physicians reported that Assessment Tool 2 supported their knowledge and assessments, but found its administration too time-consuming.
Treatment protocols and guidelines
According to most of the HCPs, the treatment protocols and guidelines within NPRL provide a common biopsychosocial language and transparency in treatment duration, intensity, and content: “In my opinion, in NPRL the treatment approach is more explicit and I know these are the steps to take to achieve a result compared to usual care.” (P2: PT, focus group 5). HCPs in local networks indicate that the protocols and guidelines provide a clear overview of the total approach in CMP management. Patients are more familiar and better informed about the content of various treatments in transmural care, compared with those treated before NPRL started. Due to the reduced number of consultations prescribed, some therapists in primary care indicated fear that this would lead to a drop in income from that achieved before NPRL’s start.
HCPs have different personal preferences and opinions about the freedom in implementation of the treatment protocol and guidelines. Some HCPs felt that this freedom was desirable as it could be adjusted to the local organization of the primary care practices: “Currently, it is not a tight protocol, of which we are the executors, searching for patients who fit. And I think the strength lies in the fact that we as HCPs can decide how to implement the knowledge that we have gained in the area of chronic pain, in a way that will fit into our daily care routines. That is an essential difference, as P10 [GP] said” (P3: PT, FG1)). This freedom might be an important facilitator, according to the HCPs, if NPRL is to be implemented in the Netherlands. Other HCPs underlined the importance of standardization, with fixed treatment protocols, as they wanted more control of the treatment of this complex patient population.
EHealth application
The participants indicated that e-health has a central position in NPRL: it facilitates and supports the patient in the treatment process, and collects biopsychosocial information about the patient. According to primary HCPs, the eHealth application is user-friendly and the collected information derived from assessment reduces the duration of consultations. However, some GPs see the collection of extra information as an extra burden for patients. Other barriers of the eHealth application mentioned were: the slow speed of the two-step authentication log-in facility, lack of an overview of the steps in the treatment, and difficulties in using the chat function in daily practice because no HCP is assigned to keep track of it. These barriers meant that some HCPs had little experience of using the eHealth application. RPs saw no added value of the diary function in the eHealth application as they did not see patients frequently enough during rehabilitation to integrate it into treatment.
All patients agreed that the eHealth application stimulated them to adhere to the treatment. Both the graphs of their daily activity and the education material provided were especially motivating: “The most important advantage of the eHealth application is the diaries: they keep me motivated. I like the competition with myself to be more active” (SP35, patient, FG6). On the other hand, it was hard for some patients to complete the diary daily so they missed the added value of this daily returning questionnaire. Also, some patients could not participate in this study because they had no internet connection.
Collaboration
Some therapists appreciated the fact that collaboration with GPs and MHPNs is a major pillar of NPRL. However, collaboration with GPs was perceived as difficult as it takes a lot of effort to contact them for consultation and discussion. At the end of Phase 1, some HCPs reported no change in levels of collaboration in local networks of NPRL. In Phases 2 and 3, more change in collaboration was reported, though this was still not optimal. Better collaboration was achieved in local networks based in one site, compared to those in which the GP and MHPN were located at a different address from the therapists. According to the HCPs in primary care, multidisciplinary collaboration in a local network will facilitate treatment of patients with more complex pain complaints, leading to a decrease in referrals to secondary or tertiary care. Also, they felt that young and dynamic teams would facilitate implementation. In the future, it is hypothesized by the HCPs that local networks and the use of eHealth applications would encourage further collaboration.
HCPs perceive a barrier when a patient needed to be referred to a non-participating practice or HCP. For these treatments, patients may be less well served as practitioners outside NPRL would not have such a detailed insight into the treatment protocols. Patients might get more biomedically oriented treatments, leading to confusion. HCPs in secondary and tertiary care thought that NPRL would especially have advantages for primary care since multidisciplinary teamwork with a focus on CMP patients is already regular care in these.
Education days and practice meetings
At the end of Phase 1, HCPs found the education days somewhat confusing. Using their feedback during these education days, the taught treatment protocol was further improved and made flexible, but it seemed that HCPs preferred a more defined protocol. Therefore, in later phases, the project team composed a more fixed treatment protocol, which was found to be clearer. Overall, they instituted a clearer layout of the education days. HCPs indicated that the visits of the project team to the primary care practices gave added value. They changed mindsets and encouraged active participation. However, after the project team left, it was difficult to maintain focus on NPRL in daily practice.
Inner setting
Mission and vision
According to some HCPs, most health care practices have a biomedically oriented vision which clashes with the biopsychosocial vision of NPRL. This may be caused by the biomedical education which they had received, as described in paragraph Dutch culture, laws, and regulations (see below). For this reason, some HCPs may feel misunderstood by their colleagues in their CMP treatment approach.
Local laws and regulations
Due to personnel shortages (for example MHPNs) and the increased workload associated with transition from secondary to primary care, HCPs in primary care have a full schedule. This hinders recruitment and active participation. In the future, the organization of care will shift towards the enlargement of primary care practices with more HCPs for the same number of patients, which could be an advantage for implementing NPRL. “Our practice is large enough to divide projects among staff, resulting in enough time and funding to participate. I think the reorganization of general practice care towards practice enlargement will be important. With more GPs in one practice, you have time for multidisciplinary collaboration” (P10, GP, FG1).
Additionally, current daily general practice care is unsuitable for networking on a large scale. There is a growing number of GPs with specializations but patients are connected to a practice based on geographical location, not on specialization, and often they are connected to only one GP in a practice. Primary HCPs do not often refer their patients to colleague GPs based on their specializations. Some HCPs in primary care commented on the complexity of NPRL. They said it was hard to implement all the new desired elements and protocols at once, finding it difficult to learn different tools at the same time when the general workload was also heavy.
Collaboration with local partners
Multidisciplinary care is not feasible for small practices in primary care because of restrictions in financing, according to the HCPs employed: i.e. their financial buffer is smaller. Some GPs have a preference for a specific therapist practice in their local network. Moreover, HCPs experience competition between physiotherapy practices and commercial rehabilitation treatment centres. As a result, practice owners neglect the screening of patients with a specific level of complexity on the assumption that this would negatively influence the number of patients able to be treated. “I have a patient who can be treated better elsewhere, but I do not work there. I think it is good if you can neglect that, I can do that, but I am not the director who is responsible for the finance. But I think this will be a barrier for the future” (P15, RP, FG5).
Outer setting
Health care insurance
Health insurance policies in the Netherlands restrict the number of physiotherapy consultations that they will reimburse. HCPs and patients saw this as a pitfall for implementing NPRL as the consultations paid for are often insufficient to learn and apply the new self-management principles. In Dutch health care in 2018, patients may purchase additional insurance packages to cover extra physiotherapy sessions. Several different packages for different numbers of therapy sessions are available but HCPs are aware that patients with a low socioeconomic status cannot afford these. Unfortunately, the highest prevalence of CMP is amongst those patients. This affects the motivation of HCPs as well when it is already known at the beginning of treatment that the number of available consultations is insufficient.
Reimbursing health care practices and organizations
Multidisciplinary patient-related meetings between HCPs in primary care are not financially covered, which is a barrier for implementation. Financing and attending multidisciplinary meetings regularly is an especial problem for small practices with only a few staff members. Besides, when practices participate in more networks for various diseases, all with additional multidisciplinary meetings, this results in even heavier workloads and burdens for a primary care practice. As patients with CMP are often confronted with comorbidities, HCPs are required to attend several meetings for the same patient, making treatment and collaboration challenging.
MHPNs have an important role in NPRL as they can reduce burdens on GP. However, GPs point out that they receive little funding for deployment of a MHPN, which is not enough to cover all CMP patients who need their help. RPs, GPs, and therapists advocate future bundled payments to facilitate multidisciplinary meetings. “I think, there should be bundled payments which also cover multidisciplinary meetings. These meetings are often with a limited number of PTs and GPs, while meetings with more disciplines and structure are needed. I think if you do not structure it with bundled payments, due to the bustle of the day, NPRL will not be rolled out more broadly.” (P4, PT, FG1).
Dutch culture, laws, and regulations
HCPs indicated that diagnosing someone with CMP makes the patient feel they are not being taken seriously. As CMP is an abstract phenomenon with large inter-individual variations in perception, patients often feel they are not understood by their HCPs, family, and friends. “Patients perceive difficulties with the fact that they are diagnosed with fibromyalgia [a subgroup of CMP]. When you bring this message, they are staring at you: they think that something is wrong with them” (P12, GP, FG2).
Overall, current health care is biomedically oriented and HCPs not participating in NPRL often share this orientation. This makes it challenging for professionals working to NPRL guidelines to discuss the patient from a biopsychosocial viewpoint. “I have problems with the fact that the practice I work in has a more hands-on view of treatment… It is difficult to convince my colleagues [of the need] for CMP rehabilitation” (P5, PT, FG3). Also, CMP is not recognized as a disease in itself, causing a lack of clarity in defining which kind of care suits these patients. During HCPs’ education, little attention is paid to the biopsychosocial model and/or patients with unexplained complaints. In addition, the content and amount of information varies per discipline. HCPs still have to check for red flags which indicate an underlying medical disease needing further treatment. This necessary biomedical screening is an important part of a proper biopsychosocial approach, but HCPs often see this as different to biopsychosocial screening. RPs felt that there were large number of unjustified referrals from primary care, indicating a lack of knowledge of CMP among GPs.
HCPs stated that they were more willing to participate in NPRL if the workload was not too heavy, as there was a pleasant ambiance in the collaboration with colleagues.
Additionally, frequently mentioned laws and regulations which hinder the implementation of eHealth include the new general data protection regulations (GDPR) and the inability to link ICT-systems, as these hinder data transferal.
Individual characteristics
Knowledge and beliefs
Matched care is perceived as an added value by HCPs. Due to stigmatization and large variations in complexity between patients, HCPs in primary care may see patients with CMP as difficult to guide. Even after participation in the educational meetings, they wanted more training to increase their competencies to refer and treat these patients adequately. “Maybe, more training about CMP education is necessary, so that we receive more tools to increase certainty” (P1, PT, FG1).
In Phase 1, the HCPs in primary care reported difficulties in recognizing and quantifying the level of complexity of patients with CMP. They estimated that they only recognized 10-20% of the CMP population during consultations, as they tended to have a prototype patient with CMP in mind. “Personally, I was frantically searching for the ideal patient to include him, following the protocol” (P3, PT, FG1). They felt uncertain and afraid to make a false diagnosis of someone suspected to have CMP as they did not want to burden the patient unnecessarily. The fact that the group of patients in primary care is diverse with a wide variety of complaints makes recognition of CMP more difficult. In Phase 3, after additional training, HCPs found recognition easier but they still desired more experience. Also, some HCPs thought that not all patients were eager to participate in a study with questionnaires and/or eHealth and for this reason they did not invite all patients to participate.
Background experiences
The difference in the level of knowledge about CMP at the start of NPRL made it difficult to adjust the content and duration of training to everyone’s needs. Some HCPs had prior experience with projects addressing CMP and with collaboration in primary care. This could have facilitated the implementation as they already had a more biopsychosocial orientation and collaborative experience but they were disappointed that the results of these previous projects had not been integrated into daily care processes.
Motivation
Reasons for HCPs to participate included providing evidence-based health care, keeping health care affordable, increasing their personal network by multidisciplinary collaboration in a matched care setting, earlier involvement in projects for patients with CMP, the scientific basis of NPRL, or the fact that their practice owners agreed to participate. HCPs saw challenges in motivating patients to participate in a biopsychosocial treatment as, in general, patients had a more biomedical focus. For example, in physiotherapy, therapists indicated that patients expected a biomedical therapy such as massage. This led to rather low participation rates. However, some patients in the final focus group emphasized the added value of exercises. “I really like my physiotherapist because I get a few exercises, such as riding the bike, walking, and exercises with a machine. That is going well. Afterwards I get also a massage, also really helpful” (SP34, patient, FG6). HCPs stated that patients already receiving biomedical treatment, often for years, are less open to a change of approach. Therapists thought that, with some patients, starting treatment with a biopsychosocial approach decreased their credibility, which made them reluctant to invite them for participation. Moreover, not all patients want to be referred to secondary or tertiary care, although this might better suit the complexity of their pain complaints, because of their good relationship with their primary care therapist.
A facilitator for recruitment is an enthusiastic HCP, which makes it easier to motivate patients to participate. Conversely, when patients are eager to participate in the biopsychosocial treatment and research study, it enthuses the HCPs. “My therapist let me see the connection between being more physically active after practising, despite the pain. When I saw this link, that was nice to see” (P34, patient, FG6).
Process
Development
According to HCPs, the iterative, bottom-up implementation strategy suits those in primary care working in CMP as it allows adjustments to situations in daily practice. “Most innovations use window dressing, first a lot of participating organizations, and after that development of the content. In NPRL, it looks like the other way around. First, the content development in a small network, which fits better with daily care” (P18: PA, FG4).
An advisory board before the start of the project and the recruitment methods of HCPs were seen as facilitators. HCPs were attracted to participate in NPRL by the project group, other participating HCPs, practice owners, a local physiotherapist network, or an advertisement. HCPs found it important that a tertiary rehabilitation centre, which has expertise in pain rehabilitation, was the intervention source of NPRL. Also, multidisciplinary meetings with the project team were seen as facilitators as they changed HCPs’ mindsets and reminded them of the active participation aspects. However, the subject of the meetings was often about getting started with NPRL, instead of experiences of working in NPRL. According to the HCPs, the project team used their input, had a fixed protocol, and communicated well. During the recruitment of health care practices, two local networks declined participation due to lack of time in their practice. They stated that they were too busy to implement a new project adequately.
Implementation
Only three local networks participated in this study, which was however perceived as positive because, in a pilot study for complex interventions, a small group of HCPs is recommended. However, the small number of networks was also a barrier as it was difficult to collaborate and refer patients efficiently. Therefore, a critical mass of health care organizations is needed for proper implementation. Non-participating practices, organizations or colleagues lacked the multidisciplinary collaboration and shared biopsychosocial vision. For example, therapists found difficulties in the collaboration when patients, entering their practice by direct access, had to be referred for additional diagnostics to a non-participating GP.
Transferability
HCPs believe that NPRL is a solution for the current gap in care for patients with CMP and they have the confidence that NPRL will be embedded in daily care. However, at the end of Phase 3, they still felt as if they were in separate practices instead of part of a local network. “Currently, it is not a common work method” (P12, GP, FG5). According to the participating HCPs, in further implementation of NPRL, it will be challenging to attract HCPs with less interest in a biopsychosocial view. Nevertheless, they were willing to assist in the recruitment of new HCPs from their network of colleagues when NPRL is expanded. They also indicated that, as the organization of primary care in general shifts towards practice enlargement with more HCPs for the same amount of patients, this could be an advantage for NPRL.
Summary
As most findings are related to several CFIR domains and constructs, extra analyses were performed. This resulted in four summaries pertaining to biopsychosocial treatment protocols and guidelines, stigmatization of CMP in society, organization of health care, and the bottom-up implementation strategy. These summaries and main findings, along with the CFIR domains and constructs, are presented in Table 2. An extensive overview can be found in S3 Table.
Table 2 Summary and main findings assigned to CFIR domains and constructs.
Summary
|
Main findings
|
CFIR
|
|
|
Domain
|
Construct
|
1. Within NPRL, treatment protocols and guidelines provide consistency and transparency in collaboration of HCPs regarding biopsychosocial language and treatment intensity, duration, and content. However, the implementation of guidelines and protocols has different barriers in daily practice
|
1A. The guidelines and protocols stimulate intensive collaboration between HCPs, such as consistency in biopsychosocial language and transparency in treatment duration, intensity, and content
|
Intervention characteristic
|
· Design Quality & Packaging
· Cost
|
Outer setting
|
-
|
Inner setting
|
· Networks & Communications
|
Characteristics of individuals
|
· Knowledge & Beliefs about the intervention
· Self-efficacy
|
Process
|
-
|
1B. HCPs experience tension between a fixed protocol and the freedom to adjust the protocol into daily practice. This is influenced by their professional preferences
|
Intervention characteristic
|
· Adaptability
· Complexity
· Design Quality & Packaging
· Cost
|
Outer setting
|
-
|
Inner setting
|
· Readiness for implementation
· Self-efficacy
|
Characteristics of individuals
|
· Knowledge & Beliefs about the intervention
|
Process
|
· Executing
|
1C. It is difficult to apply the guidelines about the eHealth application and assessment tools for satisfactory use in daily care
|
Intervention characteristic
|
· Relative advantage
· Trialability
· Complexity
· Design Quality & Packaging
· Cost
|
Outer setting
|
· Patient Needs & Resources
|
Inner setting
|
· Structural characteristics
· Readiness for implementation
|
Characteristics of individuals
|
· Knowledge & Beliefs about the intervention
· Self-efficacy
|
Process
|
· Executing
|
2. Participation and implementation are hindered because of stigmatization of CMP in society. Moreover, HCPs' approaches are often more biomedically oriented than biopsychosocially.
|
2A. In Dutch society, CMP is stigmatized because the pain is not visible.
|
Intervention characteristic
|
-
|
Outer setting
|
· Patient needs & Resources
|
Inner setting
|
-
|
Characteristics of individuals
|
· Knowledge & beliefs about the intervention
|
Process
|
-
|
2B. Because the biopsychosocial vision is less common, HCPs have difficulties with (early) recognition of patients with CMP in primary care.
|
Intervention characteristic
|
· Complexity
· Design Quality & Packaging
|
Outer setting
|
· Patient needs & Resources
|
Inner setting
|
· Culture
· Implementation climate
|
Characteristics of individuals
|
· Knowledge & beliefs about the intervention
· Self-efficacy
· Individual stage of change
|
Process
|
· Executing
|
2C. HCPs have difficulties motivating patients for a biopsychosocial treatment because the attitudes of both are more biomedically focused.
|
Intervention characteristic
|
· Complexity
· Design Quality & Packaging
|
Outer setting
|
-
|
Inner setting
|
-
|
Characteristics of individuals
|
· Self-efficacy
|
Process
|
-
|
3. The current organization of health care for patients with CMP, such as the culture, structure, and financing of health care practices, complicates the implementation between and within the practices.
|
3A. The culture of health care practices, such as the ambiance and attitude, determines the success of the collaboration between HCPs.
|
Intervention characteristic
|
-
|
Outer setting
|
· Cosmopolitanism
· External policy & incentives
|
Inner setting
|
· Structural characteristics
· Culture
· Implementation Climate
|
Characteristics of individuals
|
· Self-efficacy
|
Process
|
-
|
3B. The current organization of financing health care in the Netherlands hinders the implementation of NPRL.
|
Intervention characteristic
|
· Complexity
· Cost
|
Outer setting
|
· Patients’ needs & Resources
· Cosmopolitanism
· External Policy & Incentives
|
Inner setting
|
· Structural Characteristics
· Network & Communications
|
Characteristics of individuals
|
-
|
Process
|
-
|
3C. The structure of the organization of health care practices in primary care is complex.
|
Intervention characteristic
|
· Adaptability
· Trialability
· Complexity
· Cost
|
Outer setting
|
· Cosmopolitanism
· Peer pressure
· External Policy & Incentives
|
Inner setting
|
· Structural Characteristics
· Networks & Communications
· Implementation Climate
· Readiness for Implementation
|
Characteristics of individuals
|
· Self-efficacy
|
Process
|
-
|
4. The iterative, bottom-up implementation strategy fits with the HCPs in CMP. However, a critical mass of health care organizations is needed for proper implementation.
|
4A. The active iterative, bottom-up development and participation of HCPs and the project team in the implementation process of NPRL is seen as an advantage.
|
Intervention characteristic
|
· Intervention source
· Evidence strength & Quality
· Relative Advantage
· Adaptability
· Design Quality & Packaging
|
Outer setting
|
· Implementation Climate
|
Inner setting
|
-
|
Characteristics of individuals
|
· Knowledge & Beliefs about the intervention
· Self-efficacy
· Individual identification with Organization
|
Process
|
· Engaging
· Executing
|
4B. A critical mass of health care organizations is necessary for properly implementing NPRL.
|
Intervention characteristic
|
· Complexity
· Design Quality & Packaging
|
Outer setting
|
-
|
Inner setting
|
· Structural characteristics
· Network & Communications
· Culture
· Implementation Climate
|
Characteristics of individuals
|
-
|
Process
|
-
|
4C. HCPs believe that NPRL is a solution to the current gap in care for patients with CMP.
|
Intervention characteristic
|
· Evidence strength & Quality
· Relative Advantage
· Adaptability
|
Outer setting
|
-
|
Inner setting
|
· Structural characteristics
|
Characteristics of individuals
|
· Knowledge & Beliefs about the intervention
|
Process
|
-
|