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Introduction: The implementation of evidence-informed policies and practices across systems is a complex, multifaceted endeavor, often requiring the mobilization of multiple organizations from a range of contexts. In order to facilitate this process, policy makers, innovation developers and service deliverers are increasingly calling upon intermediaries to support implementation, yet relatively little is known about precisely how they contribute to implementation. This study examines the role of intermediaries supporting the implementation of evidence-informed policies and practices in the mental health and addictions systems of New Zealand, Ontario, Canada and Sweden. Methods: Using a comparative case study methodology and taking an integrated knowledge translation approach, we drew from established explanatory frameworks and implementation theory to address three questions: (1) Why were the intermediaries established? (2) How are intermediaries structured and what strategies do they use in systems to support the implementation of policy directions? and (3) What explains the lack of use of particular strategies? Data collection included three site visits, 49 key informant interviews and document analysis. Results: In each jurisdiction, a unique set of problems (e.g., negative events involving people with mental illness), policies (e.g., feedback on effectiveness of existing policies) and political events (e.g., changes in government) were coupled by a policy entrepreneur to bring intermediaries onto the decision agenda. While intermediaries varied greatly in their structure and characteristics, both the strategies they used and the strategies they didn't use were surprisingly similar. Specifically it was notable that none of the intermediaries used strategies that directly targeted the public, nor used audit and feedback. This emerged as the principle policy puzzle. Our analysis identified five reasons for these strategies not being employed: (1) their need to build/maintain healthy relationships with policy actors; (2) their need to build/maintain healthy relationships with service delivery system actors; (3) role differentiation with other system actors; (4) perceived lack of "fit" with the role of policy intermediaries; and (5) resource limitations that preclude intensive distributed (program-level) work. Conclusion: Policy makers and implementers must consider capacity to support implementation, and our study identifies how intermediaries can be developed and harnessed to support the implementation process. [ABSTRACT FROM AUTHOR]

Introduction: Cultural adaptation of interventions is complex and yet vital to achieving the intended benefits of interventions with new populations. However, little is known regarding deliverers' perceptions of cultural adaptation and when a cultural adaptation process can be considered complete. The purpose of this study was to explore aspects of cultural adaptation that need further attention in an intervention that had undergone an initial cultural adaptation. Methods: Four focus groups (FGs) were conducted with preschool teachers who had worked with a culturally adapted version of preschool Promoting Alternative Thinking Strategies (PATHS©) in Sweden for approximately 6 months. In total, 16 teachers from eight preschools were included, with 3-5 teachers in each group. All FGs were audio-recorded and transcribed verbatim. Thematic analysis with an inductive approach was applied to the transcribed data. Results: Three themes were identified where teachers described the need for further cultural adaptation for the intervention to align with personal and societal fundamental cultural values and be useful for their work as teachers in the Swedish preschool setting. The themes pertained to culturally adapting a manual-based intervention to a foundational, value-based approach, such as the practical application of core values and the steering documents of the Swedish preschool. Furthermore, the practical function of the culturally adapted intervention in the new cultural context revealed a further need to adjust materials and activities in interaction with the children. Finally, the prerequisites within the Swedish cultural setting, including resources and collaboration with parents as part of the work structure for preschool teachers in Sweden, needed further attention in relation to the intervention. Conclusion: The findings of this study highlight the importance of the deliverer in the cultural adaptation process in addition to adaptations that focus on end users (children in the case of preschool PATHS). Furthermore, the study indicates a need for a more open-ended view of the cultural adaptation process for interventions than perhaps previously described in models of cultural adaptation of interventions. [ABSTRACT FROM AUTHOR]

Background: Standardised terminologies and classification systems play an increasingly important role in the continuous work towards high quality patient care. Currently, a standardised terminology for nutrition care, the Nutrition Care Process (NCP) Terminology (NCPT), is being implemented across the world, with terms for four steps: Nutrition Assessment (NA), Nutrition Diagnosis (ND), Nutrition Intervention (NI) and Nutrition Monitoring and Evaluation (NME). Objective: To explore associations between individual and contextual factors and implementation of a standardised NCPT among Swedish dietitians. Method: A survey was completed by 226 dietitians, focussing on: (a) NCPT implementation level; (b) individual factors; and (c) contextual factors. Associations between these factors were explored through a two-block logistic regression analysis. Results: Contextual factors such as intention from management to implement the NCPT (OR (odds ratio) ND 15.0, 95% Confidence Interval (CI) 3.9–57.4, NME 3.7, 95% CI 1.1–13.0) and electronic health record (EHR) headings from the NCPT (OR NI 3.6, 95% CI 1.4–10.7, NME 3.8, 95% CI 1.1–11.5) were associated with higher implementation. A positive attitude towards the NCPT (model 1 OR ND 3.8, 95% CI 1.5–9.8, model 2 OR ND 5.0, 95% CI 1.4–17.8) was also associated with higher implementation, while other individual factors showed less association. Conclusion: Contextual factors such as intention from management, EHR structure, and pre-defined terms and headings are key to implementation of a standardised terminology for nutrition and dietetic care. Implications for practice: Clinical leadership and technological solutions should be considered key areas in future NCPT implementation strategies. [ABSTRACT FROM AUTHOR]

Background: Although there is growing awareness that early childhood development programs are important for a sustainable society, there is a knowledge gap about how to implement such programs. Successful implementation requires attention to implementation drivers (competency, organization, and leadership) during all phases of the implementation. The purpose of this study was to describe cross-sectoral operational workgroups' perceptions of facilitators, barriers and solutions related to implementation drivers in the preparationphase of implementing an evidence-based early childhood home visiting program. Methods: Quantitative and qualitative data were collected from twenty-four participants, divided into 5 groups, during implementation planning workshops. The workshops were guided by a structured method informed by the principles of Motivational Interviewing and within a framework of implementation drivers. Groups sorted cards with statements representing implementation drivers according to perceptions of facilitators and barriers, and percentages were calculated for each type of implementation determinant, for each type of driver. The groups discussed their card sorting and wrote action plans to address barriers, yielding documentation that was analyzed using deductive qualitative content analysis. Results: A mixed-methods analysis resulted identification of facilitators, barriers, unknowns and solutions in two to three subcategories under each main category of implementation driver. A competent and confident workforce, and enthusiasm and commitment were key facilitators. Key barriers were unclear roles and responsibilities, and insufficient articulation of local vision and goals. Many factors were described as yet unknown. Specific solutions were generated to support the implementation. Conclusions: Our study furthers the scientific understanding of how to take evidence-based early childhood programs from research to practice within an implementation drivers framework. Facilitators, barriers and solutions in key areas during the preparation phase were identified with the help of a novel tool. The results provide useful knowledge for decision makers and organizations preparing similar initiatives in communities striving to attain sustainable development goals. [ABSTRACT FROM AUTHOR]

Prior to a multifaceted implementation strategy for a healthy lifestyle-promoting practice the expectations of primary health care managers, appointed internal facilitators and health care professionals on supporting change was explored. This study had an explorative qualitative design using data gathered from individual interviews and focus groups. Qualitative content analysis with a deductive category development was applied using the Consolidated Framework for Implementation Research. The study was conducted in a primary care setting in central Sweden as a part of the Act in Time research project. Prior to a multifaceted implementation strategy, we held 16 individual interviews with managers and appointed facilitators and five focus groups with 26 health care professionals. Managers, facilitators, and professionals held similar expectations, where their expressed need for support corresponded to three constructs: Readiness for implementation, Implementation climate, and Engaging. Our findings indicate the need for strong leadership engagement to focus on how the healthy lifestyle-promoting practice can be anchored among the professionals. Managers at all levels should communicate the vision and goals, enable facilitators and professionals to improve their competencies, build inter-professional teams, and jointly plan the new practice. To change to a healthy lifestyle promoting practice professionals request support from their managers, who in turn need support from the middle and top managers. The requested support includes helping to prioritise health promotion and enabling the primary care centres to build competence and take ownership of the implementation. ClinicalTrials.gov NCT04799860 This study revealed that primary health care managers and health care professionals had mutual expectations of supporting a change into a healthy lifestyle-promoting practice before implementation. Strong leadership engagement was perceived as essential across all manager levels, including assistance in prioritising health promotion. The support should enable primary health care centres to build competence and have ownership of implementing a healthy lifestyle-promoting practice. [ABSTRACT FROM AUTHOR]

Background: Research shows that interventions to protect the sensitive physiological process of birth by improving the birthing room design may positively affect perinatal outcomes. It is, however, crucial to understand the mechanisms and contextual elements that influence the outcomes of such complex interventions. Hence, we aimed to explore care providers' experiences of the implementation of a new hospital birthing room designed to be more supportive of women's birth physiology. Methods: This qualitative study reports on the implementation of the new birthing room, which was evaluated in the Room4Birth randomised controlled trial in Sweden. Individual interviews were undertaken with care providers, including assistant nurses, midwives, obstetricians, and managers (n = 21). A content analysis of interview data was conducted and mapped into the three domains of the Normalisation Process Theory coding manual: implementation context, mechanism, and outcome. Results: The implementation of the new room challenged the prevailing biomedical paradigm within the labour ward context and raised the care providers' awareness about the complex interplay between birth physiology and the environment. This awareness had the potential to encourage care providers to be more emotionally present, rather than to focus on monitoring practices. The new room also evoked a sense of insecurity due to its unfamiliar design, which acted as a barrier to integrating the room as a well-functioning part of everyday care practice. Conclusion: Our findings highlight the disparity that existed between what care providers considered valuable for women during childbirth and their own requirements from the built environment based on their professional responsibilities. This identified disparity emphasises the importance of hospital birthing rooms (i) supporting women's emotions and birth physiology and (ii) being standardised to meet care providers' requirements for a functional work environment. Trial registration: ClinicalTrials.gov: NCT03948815, 14/05/2019. [ABSTRACT FROM AUTHOR]

Background: There is moderate to strong evidence of the effectiveness of health-promotion interventions, but implementation in routine primary health care (PHC) has been slow. In the Act in Time project implementation support is provided for a health promotion practice using individually targeted lifestyle interventions in a PHC setting. Identifying health care professionals' (HCPs') perceptions of barriers and facilitators helps adapt implementation activities and achieve a more successful implementation. This study aimed, at a pre-implementation stage, to describe the expectations of managers, appointed internal facilitators (IFs) and HCPs on implementing a healthy lifestyle-promoting practice in PHC. Methods: In this qualitative study five focus group discussions with 27 HCPs and 16 individual interviews with managers and appointed IFs were conducted at five PHC centres in central Sweden. The PHC centres are participating in the Act in Time project, evaluating the process and outcomes of a multifaceted implementation strategy for a healthy lifestyle-promoting practice. A deductive qualitative content analysis based on the Consolidated Framework for Implementation Research (CFIR) was followed using inductive analysis. Results: Twelve constructs from four of five CFIR domains were derived: Innovation characteristics, Outer setting, Inner setting, and Characteristics of individuals. These domains are related to the expectations of HCPs to implement a healthy lifestyle-promoting practice, which includes facilitating factors and barriers. The inductive analysis showed that the HCPs perceived a need for a health-promotion approach to PHC. It serves the needs of the patients and the expectations of the HCPs, but lifestyle interventions must be co-produced with the patient. The HCPs expected that changing routine practice into a healthy lifestyle-promoting practice would be challenging, requiring sustainability, improved structures, cooperation in inter-professional teams, and a common purpose. A collective understanding of the purpose of changing practice was vital to successful implementation. Conclusions: The HCPs valued implementing a healthy lifestyle-promoting practice in a PHC setting. However, changing routine methods was challenging, implying that the implementation strategy should address obstacles and facilitating factors identified by the HCPs. Trial registration: This study is part of the Act in Time project, registered in ClinicalTrials.gov with the number NCT04799860. Registered 03 March 2021. [ABSTRACT FROM AUTHOR]

Advance care planning (ACP) is a process involving conversations about values and preferences regarding future care at the end-of-life. ACP has led to positive outcomes, both in relation to quality of life and with increased use of palliative care, less life-sustaining treatment and fewer hospital admissions. Sweden has yet to embrace the practice systematically, but scattered initiatives exist. To study implementation of a routine for ACP in NH settings in Sweden by exploring healthcare professionals' experiences of engaging in ACP following this implementation. The study followed a qualitative inductive design with convenience and snowball sampling. Semi-structured group and individual interviews with registered healthcare professionals were analysed using qualitative content analysis. Organisational support for sustainable ACP implementation was found to be essential. This included sufficient training, facilitation, collaboration and uniform work routines across providers and professionals. Engaging in ACP conversations following the implemented routine was found to be a process of preparing, being, talking, deciding and sharing. Successful implementation of ACP in NHs requires a carefully planned implementation strategy. ACP in NHs tend to be medically focused at the expense of residents' psychosocial care-planning needs. Widespread uptake of ACP in Sweden could be useful in the national effort to adopt more person-centred care in Swedish healthcare. While advance care planning has been implemented in many other countries, Sweden lacks a national strategy on advance care planning and Swedish healthcare settings have yet to systematically implement this practice. • This study is the first to report on professionals' experiences of engaging in sustainable advance care planning, following top-down implementation of the practice in one Swedish region. • Successful implementation of advance care planning in nursing homes requires a system-level approach, and shortcomings of the implementation process are highlighted. [ABSTRACT FROM AUTHOR]

Background: Evidence-based practice (EBP) is fundamental to the delivery of high-quality, safe and effective health care. Naprapaths, manual therapy providers that specialize in the treatment of musculoskeletal pain and dysfunction, became a Swedish licensed health profession in 1994. This study investigated the attitudes, skills and implementation of EBP among licensed naprapaths in Sweden. Methods: Licensed naprapaths (n = 950) of Svenska Naprapatförbundet (the Swedish Naprapathy Association) were invited by email to take part in this cross-sectional anonymous online study using the Evidence-Based Practice Attitude and Utilisation Survey in February 2019. Results: Fourteen percent (137/950) of invited naprapaths completed the survey. There was an approximately equal gender divide among responders; most were in the mid-career age range, practiced in city areas, and had a university or college certificate/diploma as their highest qualification. The majority of naprapaths agreed or strongly agreed that EBP was necessary in the practice of naprapathy, assisted them in making care decisions, and improved the quality of patient care. Naprapaths' self-reported skills in EBP were mostly in the moderate to moderate-high range. The majority of participating naprapaths reported infrequent implementation of EBP. Perceived minor or moderate barriers to EBP uptake included a lack of colleague support for EBP and a lack of relevant resources. Access to the internet and free online databases were reported as very useful enablers to improving EBP uptake. Conclusions: The licensed naprapaths participating in this survey reported positive attitudes toward EBP, moderate levels of EBP skills, and infrequent implementation of EBP. [ABSTRACT FROM AUTHOR]

To identify facilitators of and barriers to the coordination of return-to-work between the primary care services, the employee, and the employers from the perspective of coordinators and employees on sick leave due to common mental disorders (CMDs). Descriptive qualitative study. Semi-structured interviews were conducted with eighteen coordinators and nine employees on sick leave due to CMDs. The Consolidated Framework for Implementation Research (CFIR) was used as a starting point for the interview guides and in the thematic analysis of data. The results show facilitators and barriers related to the CFIR domains "intervention characteristics," "outer setting," "inner setting," and "characteristics of individuals." Positive attitudes, an open dialogue in a three-party meeting, and a common ground for the sick leave process at the primary care centre facilitated coordination, while an unclear packaging, conflicts at the employee's workplace, and a lack of team-based work were examples of barriers. The results indicate a need for the detailed packaging of coordination; formalization of coordinators' qualifications and levels of training; and acknowledgement of the role of organizational factors in the implementation of coordination. This is important to further develop and evaluate the efficacy of coordination. Positive attitudes to coordination, an open dialogue in a three-party meeting, leadership engagement, routines for the return to work (RTW) process at the primary care centre, and collegial alliances were identified as facilitators. An unclear packaging of the intervention, conflicts at the employee's workplace, lack of team-based work, and lack of coordinator training were identified as barriers. A detailed intervention packaging adapted for the specific setting and formalization of coordinators' qualifications and training is necessary for coordination of RTW. Recognizing organizational factors were identified as being important for the implementation of coordination of RTW for persons on sick leave due to CMDs. [ABSTRACT FROM AUTHOR]

Aim: To analyse the transfer of knowledge on how to detect physical abuse, especially shaken baby syndrome/abusive head trauma (SBS/AHT), and its association to trends in infant abuse diagnoses (maltreatment and assault).Methods: Design: retrospective population-based and quasi-experimental.Setting: Sweden 1987-2019.Patients: Children below age 1 year, selected from the National Patient Register (n = 1150). Exposures: Literature search for transfer of knowledge by diffusion, dissemination and implementation, and whether supportive or disruptive of the SBS/AHT paradigm.Main Outcome Measure: Abuse diagnoses (maltreatment or assault).Analyses: Incidence rate, incidence rate ratio (IRR).Results: The overall incidence rate of abuse was 32.23 per 100,000 during the years 1987-2019. It was rather stable 1987-2000. The SBS diagnosis was introduced in the late 1990s. A comprehensive increase of transfer of knowledge on physical abuse, specifically on SBS/AHT and dangers of shaking, took place from 2002 and onward through diffusion, dissemination and implementation. Maltreatment diagnoses, but not assault diagnosis, increased steeply during 2002-2007, peaking in 2008-2013 [IRR 1.63 (95% confidence interval 1.34-1.98)]. Transfer of disruptive knowledge on SBS/AHT during the period 2014-2019 was associated with a decline in maltreatment diagnoses [IRR 0.84 (95% confidence interval 0.71-0.99)].Conclusion: An increase in maltreatment diagnoses was associated with transfer of supportive knowledge of the SBS/AHT paradigm, while a decline occurred toward the end of the study period, which might indicate a burgeoning de-implementation process. [ABSTRACT FROM AUTHOR]

Background: International and national guidelines state that palliative care should be offered to everyone who needs it. To promote the implementation of palliative care in nursing homes, a partnership collaboration was initiated with the goal of implementing high quality palliative care. The partnership consisted of three partner groups: a project group from a non-profit organisation providing health care, managers at the nursing homes and an academic partner. The aim was to explore the social processes within academic-community partnership in a collaboration project. Methods: Digital focus group discussions were conducted with 16 participants, representing all three partner groups. One individual digital interview was also carried out. A constructivist perspective of a grounded theory approach was used for data analysis. Results: The core category, partnership positioning, covers the social processes of the academic-community partnership in a collaboration project to implement and evaluate health-promoting interventions in clinical health care. The core category was found to have four categories: Pre-positioning, Co-positioning, Re-positioning and GoOn-positioning. The process of partnership positioning is conceptualised in a model. Conclusions: Our findings indicate that a new partnership in an implementation project needs holistic, systemic thinking. To enhance implementation in a collaborative project involving different professionals and actors a plan is required to facilitate positioning activities. The process, the roles and the components need to be clearly defined and documented, and the management of a system requires knowledge of the interrelationships between all the components within the system. The development of a conceptual model of Partnership Positioning contributes to knowledge concerning the social dynamic processes which can be applied to support future academic-community collaboration and/or implementation projects. Trial registration: Not applicable. The present study has not been considered as a clinical trial. [ABSTRACT FROM AUTHOR]

Background: Providing secondary prevention through structured and comprehensive cardiac rehabilitation programmes to patients after a myocardial infarction (MI) reduces mortality and morbidity and improves health-related quality of life. Cardiac rehabilitation has the highest recommendation in current guidelines. While treatment target attainment rates at Swedish cardiac rehabilitation centres is among the highest in Europe, there are considerable differences in service delivery and variations in patient-level outcomes between centres. In this trial, we aim to study whether centre-level guideline adherence and patient-level outcomes across Swedish cardiac rehabilitation centres can be improved through a) regular audit and feedback of cardiac rehabilitation structure and processes through a national quality registry and b) supporting cardiac rehabilitation centres in implementing guidelines on secondary prevention. Furthermore, we aim to evaluate the implementation process and costs., Methods: The study is an open-label cluster-randomized effectiveness-implementation hybrid trial including all 78 cardiac rehabilitation centres (attending to approximately 10 000 MI patients/year) that report to the SWEDEHEART registry. The centres will be randomized 1:1:1 to three clusters: 1) reporting cardiac rehabilitation structure and process variables to SWEDEHEART every six months (audit intervention) and being offered implementation support to implement guidelines on secondary prevention (implementation support intervention); 2) audit intervention only; or 3) no intervention offered. Baseline cardiac rehabilitation structure and process variables will be collected. The primary outcome is an adherence score measuring centre-level adherence to secondary prevention guidelines. Secondary outcomes include patient-level secondary prevention risk factor goal attainment at one-year after MI and major adverse coronary outcomes for up to five-years post-MI. Implementation outcomes include barriers and facilitators to guideline adherence evaluated using semi-structured focus-group interviews and relevant questionnaires, as well as costs and cost-effectiveness assessed by a comparative health economic evaluation., Discussion: Optimizing cardiac rehabilitation centres' delivery of services to meet standards set in guidelines may lead to improvement in cardiovascular risk factors, including lifestyle factors, and ultimately a decrease in morbidity and mortality after MI., Trial Registration: ClinicalTrials.gov. Identifier: NCT05889416 . Registered 2023-03-23., (© 2024. The Author(s).)

Background: Person-centred care (PCC) is promoted as an innovation that will improve patients' rights and increase their participation in healthcare. Experience shows that the implementation of PCC is challenging and often results in varying levels of adoption. How health care professionals (HCPs) perceive an innovation such as PCC is an important factor to consider in implementation. Yet, such studies are scarce. Thus, in a sample of healthcare units in a region in Sweden, involved in a transition to PCC, we aimed to investigate HCPs' perceptions of PCC.Methods: An interview study was conducted in 2018 during the implementation of PCC with HCPs (n = 97) representing diverse vocational roles in six healthcare contexts. Data were collected via focus groups (n = 15), dyadic interviews (n = 5), and individual interviews (n = 22) and analysed using a deductive-inductive content analysis. The deductive approach was guided by the Consolidated Framework for Implementation Research (CFIR), followed by an inductive analysis to describe HCPs' in-depth perceptions of PCC in relation to each of the CFIR constructs.Results: Eight constructs from two of the CFIR domains, Intervention characteristics and Inner setting, were used to code HCPs' perceptions of PCC. One construct, Observability, was added to the coding sheet to fully describe all the data. The constructs Relative advantage, Complexity, Compatibility, Observability, and Available resources were discussed in depth by HCPs and resulted in rich and detailed data in the inductive data analysis. This analysis showed large variations in perceptions of PCC among HCPs, based on factors such as the PCCs ethical underpinnings, its operationalisation into concrete working routines, and each HCPs' unique recognition of PCC and the value they placed on it.Conclusions: We identified nine CFIR constructs that seem pertinent to HCPs' perceptions of PCC. HCPs report an array of mixed perceptions of PCC, underlining its complex nature. The perceptions are shaped by a range of factors, such as their individual understandings of the concept and the operationalisation of PCC in their local context. Stakeholders in charge of implementing PCC might use the results as a guide, delineating factors that may be important to consider in a wide range of healthcare contexts. [ABSTRACT FROM AUTHOR]

What is known and objective: Drug‐related problems (DRPs) are a growing healthcare burden worldwide. In an ongoing cluster‐randomized controlled trial in Sweden (MedBridge), comprehensive medication reviews (CMRs) including post‐discharge follow‐up have been conducted in older hospitalized patients to prevent and solve DRPs. As part of a process evaluation of the MedBridge trial, this study aimed to assess the intervention fidelity and process outcomes of the trial's interventions. Methods: For intervention delivery, the percentage of patients that received intervention components was calculated per study group. Process outcomes, measured in about one‐third of all intervention patients, included the following: the number of identified medication discrepancies, DRPs and recommendations to solve DRPs, correction rate of discrepancies, and implementation rate of recommendations. Results and discussion: The MedBridge trial included 2637 patients (mean age: 81 years). The percentage of intervention patients (n = 1745) that received the intended intervention components was 94%‐98% during admission, and 40%‐81% upon and after discharge. The percentage of control patients (n = 892) that received at least one unintended intervention component was 15%. On average, 1.1 discrepancies and 2.0 DRPs were identified in 652 intervention patients. The correction and implementation rates were 79% and 73%, respectively. Stop medication was the most frequently implemented recommendation (n = 293) and 77% of the patients had at least one corrected discrepancy or implemented recommendation. What is new and conclusion: The intervention fidelity within the MedBridge trial was high for CMRs during hospital stay and lower for intervention components upon and after discharge. The high prevalence of corrected discrepancies and implemented recommendations may explain potential effects of CMRs in the MedBridge trial. [ABSTRACT FROM AUTHOR]

Background: Increasing interest in implementation science has generated a demand for education and training opportunities for researchers and practitioners in the field. However, few implementation science courses have been described or evaluated in the scientific literature. The aim of the present study was to provide a short- and long-term evaluation of the implementation training at Linköping University, Sweden.Methods: Two data collections were carried out. In connection with the final seminar, a course evaluation form, including six items on satisfaction and suggestions for improvement, was distributed to the course participants, a total of 101 students from 2011 to 2015 (data collection 1), response rate 72%. A questionnaire including six items was distributed by e-mail to the same students in autumn 2016 (data collection 2), response rate 63%. Data from the two data collections were presented descriptively and analysed using the Kirkpatrick model consisting of four levels: reaction, learning, behaviour and results.Results: The students were very positive immediately after course participation, rating high on overall perception of the course and the contents (reaction). The students also rated high on achievement of the course objectives and considered their knowledge in implementation science to be very good and to a high degree due to course participation (learning). Knowledge gained from the course was viewed to be useful (behaviour) and was applied to a considerable extent in research projects and work apart from research activities (results).Conclusions: The evaluation of the doctoral-level implementation science course provided by Linköping University showed favourable results, both in the short and long term. The adapted version of the Kirkpatrick model was useful because it provided a structure for evaluation of the short- and long-term learning outcomes. [ABSTRACT FROM AUTHOR]

The present study examined proximal and distal barriers and supports within the Swedish service system that may affect implementation of early and intensive behavioral intervention (EIBI) for children with autism. A case study approach with roots in ethnography was chosen to explore this issue. Two preschools exemplifying 'high quality practice' were studied and information was collected through multiple sources during a 12 month period, this included participant observations, direct observations, semi-structured interviews with key informants; paraprofessionals, parents, special educators, habilitation specialists and a focus group interview. Interview transcripts and field notes were combined and analyzed using an abductive grounded theory approach. Findings highlight the relevance of researchers understanding and taking into consideration the effect that distal variables have on implementation within proximal settings. A theoretical model of factors affecting implementation was conceptualised to include: staff entry knowledge and competence, development through supervision, the role of the preschool administrator, as well as distal influences and inter-organizational tensions, values, and bridges. Findings are discussed within the context of implementation science. Implications for future research are discussed as well as areas in need of further development to bridge the gap between research and practice. [ABSTRACT FROM AUTHOR]

Background: Young people are disproportionally burdened by sexual ill health. The SEXual health Identification Tool (SEXIT) was developed for use at youth clinics, to facilitate identification of visitors exposed to or at risk of sexual ill health. The aim of this study was to explore experiences of using SEXIT among youth clinic staff who participated in a pilot implementation, with a focus on usefulness, implementation determinants, and feasibility of implementing SEXIT at Swedish youth clinics., Methods: Four focus group discussions were conducted with youth clinic staff from three clinics. The clinics had used SEXIT systematically in consultations with all visitors for one month. Data were analysed using qualitative analysis designed for focus groups., Results: Most participants experienced that the SEXIT routines were well functioning and that using SEXIT gave a comprehensive picture of the visitor and resulted in more concrete answers, which facilitated the risk assessment. The medical staff experienced that they identified more youth at risk with SEXIT, while the psychosocial staff were less convinced. Existing challenges related to the routines at the clinics and heavy workload during drop-in hours., Conclusions: Staff experience SEXIT as useful for identifying young people exposed to or at risk of sexual ill health. Systematic use ensures consistency and quality in assessing the visitors, which may facilitate implementation. The use of SEXIT is challenged by heavy workload, conflicting routines, and the experience that some visitors identified through SEXIT decline further care. Implementation of SEXIT in Swedish youth clinics is considered feasible., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: A psychosocial dementia care programme for challenging behaviour (DEMBASE ® ) was developed in collaboration with a Swedish BPSD-registry team for in-home care services use in Japan. The programme consisted of a web-based tool for the continued assessment of challenging behaviours and interdisciplinary discussion meetings. Effectiveness of the adapted programme was verified through a cluster-randomised controlled trial. The Tokyo Metropolitan Government provided municipal funding to introduce the programme into daily practice beginning in April 2018., Objectives: To investigate both facilitators and barriers associated with programme implementation., Design: A secondary analysis of qualitative and quantitative data., Settings: Data were collected in naturalistic long-term care settings from April 2018 to March 2019., Participants: A total of 138 professionals and 157 people with dementia participated in the programme., Methods: Challenging behaviour in persons with dementia was assessed by professionals using a total Neuropsychiatric Inventory score. Data on expected facilitators and barriers were extracted for qualitative analysis from a debriefing meeting between professionals., Results: Of the 157 persons with dementia, 81 (51.6%) received follow-up behavioural evaluations by March 2019. The average level of challenging behaviour was significantly reduced for 81 persons from baseline to their most recent follow-up evaluations. Facilitators included 'programme available for care managers', 'visualised feedback on professionals' work', 'affordable for providers and professionals' and 'media coverage'. Barriers included 'professionals from different organisations', 'unpaid work', 'operation requirement for municipalities' and 'conflict with daily benefit-oriented framework'., Conclusions: A follow-up evaluation was not fully achieved. Further strategies to address barriers may include the development of a benefit-rewarding scheme for interdisciplinary discussion meetings, an e-learning system capable of substituting training course portions and a cross-municipality training course., (© 2020 Nordic College of Caring Science.)

Background: Health Technology Reassessment (HTR) is a process that systematically assesses technologies that are currently used in the health care system. The process results in four outputs: increase use or decrease use, no change, or de-adoption of a technology. Implementation of these outputs remains a challenge. The Knowledge Translation (KT) field enables to transfer/translate knowledge into practice. KT could help with implementation of HTR outputs. This study sought to identify which characteristics of KT theories, models, and frameworks could be useful, specifically for decreased use or de-adoption of a technology., Methods: A qualitative descriptive approach was used to ascertain the perspectives of international KT and HTR experts on the characteristics of KT theories, models, and frameworks for decreased use or de-adoption of a technology. One-to-one semi-structured interviews were conducted from September to December 2019. Interviews were audio recorded and transcribed verbatim. Themes and sub-themes were deduced from the data through framework analysis using five distinctive steps: familiarization, identifying an analytic framework, indexing, charting, mapping and interpretation. Themes and sub-themes were also mapped to existing KT theories, models, and frameworks., Results: Thirteen experts from Canada, United States, United Kingdom, Australia, Germany, Spain, and Sweden participated in the study. Three themes emerged that illustrated the ideal traits: principles that were foundational for HTR, levers of change, and steps for knowledge to action. Principles included evidence-based, high usability, patient-centered, and ability to apply to the micro, meso, macro levels. Levers of change were characterized as positive, neutral, or negative influences for changing behaviour for HTR. Steps for knowledge to action included: build the case for HTR, adapt research knowledge, assess context, select interventions, and assess impact. Of the KT theories, models, and frameworks that were mapped, the Consolidated Framework for Implementation Research had most of the characteristics, except ability to apply to micro, meso, macro levels., Conclusions: Characteristics that need to be considered within a KT theory, model, and framework for implementing HTR outputs have been identified. Consideration of these characteristics may guide users to select relevant KT theories, models, and frameworks to apply to HTR projects.

Background: Children's participation in health care is one of the most important components in the management of their disease. Electronic health (eHealth) services that are adapted to the needs of children have the potential for restructuring how children and professionals work together. Therefore, a digital interactive assessment and communication tool, Sisom, was developed to give children aged between 6 and 12 years a voice in their own health care. However, the implementation of eHealth services such as Sisom in daily practice in pediatric health care is rarely investigated.Objective: The aim of this study was to explore the process of implementing Sisom for children in pediatric care in Sweden. More specifically, the study aimed to (1) evaluate whether the implementation strategy was conducted as planned, (2) understand the barriers and facilitators of the implementation strategy in pediatric care settings, (3) gain insight into how professionals work with the specific intervention, and (4) gain insight into the usefulness and effects of the intervention from the professionals' perspectives.Methods: A process evaluation design was used to study the implementation of Sisom at 4 pediatric care centers in Sweden. An extensive amount of qualitative and quantitative data was collected before, during, and after the intervention through self-report checklists, memos, and interviews with professionals. In total, 46 children, aged between 6 and 13 years, participated. The children used Sisom on two occasions during 6 months. When they used Sisom, a printed report formed the basis for a forthcoming dialogue between professionals, children, and their parents.Results: To our knowledge, this is the first implementation study of an eHealth communication tool aimed at strengthening children's participation in pediatric health care. Key factors for successful implementation were alignment of the solution with the values and goals of the organization, health care professionals' beliefs in the usefulness and usability of the solution, and health care professionals' willingness to change their professional roles guided by the solution.Conclusions: The results from the study show that it is possible to restructure health care delivery toward a child-centered approach, if there is a willingness and preparedness in the organization to implement an eHealth solution with the aim of restructuring the way of working with children's participation. [ABSTRACT FROM AUTHOR]

Background: The uptake of evidence-based knowledge in practice is influenced by context. Observations are suggested as a valuable but under-used approach in implementation research for gaining a holistic understanding of contexts., Aim: The aim of this paper is to demonstrate how data from observations can provide insights about context and evidence use in implementation research., Methods: Data were collected over 24 months in a randomised trial with an embedded realist evaluation in 24 nursing homes across four European countries; notes from 183 observations (representing 335 hours) were triangulated with interview transcripts and context survey data (from 357 staff interviews and 725 questionnaire responses, respectively)., Results: Although there were similarities in several elements of context within survey, interview and observation data, the observations provided additional features of the implementation context. In particular, observations demonstrated if and how the resources (staffing and supplies) and leadership (formal and informal, teamwork, and professional autonomy) affected knowledge use and implementation. Further, the observations illuminated the influence of standards and the physical nursing environment on evidence-based practice, and the dynamic interaction between different aspects of context., Linking Evidence to Action: Although qualitative observations are resource-intensive, they add value when used with other data collection methods, further enlightening the understanding of the implementation context and how evidence use and sharing are influenced by context elements. Observations can enhance an understanding of the context, evidence use and knowledge-sharing triad in implementation research., (© 2020 The Authors. Worldviews on Evidence-based Nursing published by Wiley Periodicals LLC on behalf of Sigma Theta Tau International.)

Background: In a quasi-experimental study, facilitation was used to support implementation of the behavioral medicine approach in physiotherapy. The facilitation consisted of an individually tailored multifaceted intervention including outreach visits, peer coaching, educational materials, individual goal-setting, video feedback, self-monitoring in a diary, manager support, and information leaflets to patients. A behavioral medicine approach implies a focus on health related behavior change. Clinical behavioral change was initiated but not maintained among the participating physiotherapists. To explain these findings, a deeper understanding of the implementation process is necessary. The aim was therefore to explore the impact mechanisms in the implementation of a behavioral medicine approach in physiotherapy by examining dose, reach, and participant experiences., Methods: An explorative mixed-methods design was used as a part of a quasi-experimental trial. Twenty four physiotherapists working in primary health care were included in the quasi-experimental trial, and all physiotherapists in the experimental group (n = 15) were included in the current study. A facilitation intervention based mainly on social cognitive theory was tested during a 6-month period. Data were collected during and after the implementation period by self-reports of time allocation regarding participation in different implementation methods, documentation of individual goals, ranking of the most important implementation methods, and semi-structured interviews. Descriptive statistical methods and inductive content analysis were used., Results: The physiotherapists participated most frequently in the following implementation methods: outreach visits, peer coaching, educational materials, and individual goal-setting. They also considered these methods to be the most important for implementation, contributing to support for learning, practice, memory, emotions, self-management, and time management. However, time management support from the manager was lacking., Conclusions: The findings indicate that different mechanisms govern the initiation and maintenance of clinical behavior change. The impact mechanisms for initiation of clinical behavior change refers to the use of externally initiated multiple methods, such as feedback on practice, time management, and extrinsic motivation. The lack of self-regulation capability, intrinsic motivation, and continued support after the implementation intervention period were interpreted as possible mechanisms for the failure of maintaining the behavioral change over time.

This research addressed the introduction of a computerized decision support system for drug monitoring to be used by registered nurses in nursing homes. The system was introduced, and its effects were evaluated over the period of 1 year; however, at the end of 1 year, the implementation was not successful in all the participating settings. The aim of this study was to identify the conditions needed for the successful implementation of a computerized decision support system from the registered nurses' perspective. Two case sites were purposively selected based on the implementation's success in one nursing home, but not in the other. Focus group discussions were performed, one in each setting, with eight registered nurses. An inductive thematic analysis was conducted. The findings revealed six themes illustrating the registered nurses' views about the conditions needed: need to see benefits, have the time and take the time, curb administrative hassle, collaboration at all levels, stated responsibility, and requirements set from managerial positions. The most outstanding findings, when compared with the previous implementations of nursing informatics, involved collaboration and the view of drug monitoring responsibility in relation to themselves and the physicians.

Objectives: To explore healthcare professionals' experiences of implementing clinical education of medical students in communities of practice that previously focused on the delivery of healthcare services., Methods: Seven focus group interviews involving assistant nurses, nurses, and physicians were conducted at a regional hospital in Sweden. A total of 35 respondents participated. Open-ended questions were used to explore respondents' experiences of medical students in their community. Data were analysed using qualitative inductive content analysis., Results: Three main themes emerged: Staff members becoming learners, structural and sociocultural changes due to the implementation, and features designing the settings of the implementation. Reflection and interactive learning processes among staff, patients, and students were found to stimulate individual learning, to improve the learning climate in the organisation, and to enhance the structure of the clinical work. Attitudes to education among staff members as well awareness of how education is organised appeared to be vital for their experiences and approaches., Conclusions: Implementing clinical education of medical students at a hospital previously focused on delivery of care was acknowledged to not only stimulate learning among staff but also trigger structural and cultural development in communities of practice. Opportunities for interprofessional interaction and reflection are vital to successfully implement a new student group in communities of practice. Addressing conceptions about and attitudes toward the clinical education of students among healthcare professionals are essential to promote their engagement in education.

Background: The original British instrument the Normalization Process Theory Measure (NoMAD) is based on the four core constructs of the Normalization Process Theory: Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring. They represent ways of thinking about implementation and are focused on how interventions can become part of everyday practice., Aim: To translate and adapt the original NoMAD into the Swedish version S-NoMAD and to evaluate its psychometric properties based on a pilot test in a health care context including in-hospital, primary, and community care contexts., Methods: A systematic approach with a four-step process was utilized, including forward and backward translation and expert reviews for the test and improvement of content validity of the S-NoMAD in different stages of development. The final S-NoMAD version was then used for process evaluation in a pilot study aimed at the implementation of a new working method for individualized care planning. The pilot was executed in two hospitals, four health care centres, and two municipalities in a region in northern Sweden. The S-NoMAD pilot results were analysed for validity using confirmatory factor analysis, i.e. a one-factor model fitted for each of the four constructs of the S-NoMAD. Cronbach's alpha was used to ascertain the internal consistency reliability., Results: In the pilot, S-NoMAD data were collected from 144 individuals who were different health care professionals or managers. The initial factor analysis model showed good fit for two of the constructs (Coherence and Cognitive Participation) and unsatisfactory fit for the remaining two (Collective Action and Reflexive Monitoring) based on three items. Deleting those items from the model yielded a good fit and good internal consistency (alphas between 0.78 and 0.83). However, the estimation of correlations between the factors showed that the factor Reflexive Monitoring was highly correlated (around 0.9) with the factors Coherence and Collective Action., Conclusions: The results show initial satisfactory psychometric properties for the translation and first validation of the S-NoMAD. However, development of a highly valid and reliable instrument is an iterative process, requiring more extensive validation in various settings and populations. Thus, in order to establish the validity and reliability of the S-NoMAD, additional psychometric testing is needed.