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Background

Healthy-lifestyle-promoting practices are recommended to reduce the prevalence of non-communicable diseases and increase health, but are underutilized in Swedish primary health care (PHC). As part of the Act in Time project, a 12-month multifaceted implementation intervention to support the uptake of a clinical intervention offering lifestyle-screening forms and counselling to patients with planned visits, was evaluated in a PHC setting. This study aimed to explore the experiences of PHC professionals, internal facilitators, and managers working with health promotion after receiving the 12-month implementation intervention.

Methods

A qualitative study was conducted at five PHC units in Sweden using interviews with managers (n = 9) and internal facilitators (n = 10) and focus group discussions (n = 5) with physicians, nurses, counsellors, and physiotherapists (n = 18). The data were analysed with qualitative content analysis, first inductively and then deductively by mapping the data against the 12 constructs of Normalization Process Theory.

Results

Implementation of the health-promoting practice was affected by contextual factors such as attitudes and available resources. The group dynamics at the PHC centres and the managers’ role as leaders were important for finding solutions to enact the health-promotion practice.

Health-promotion practice was seen as a natural development of PHC. A common focus and opportunity to influence created a sense of coherence. Feelings of autonomy enabled the professionals to collaborate and strengthened participation in the implementation intervention. The internal facilitators helped to guide the PHC centres forward in the implementation process and created strategies to integrate the health-promotion practice into existing clinical practice.

Uptake of the clinical intervention led to a more structural and holistic way of working with lifestyle habits, with patients taking an active part. The professionals’ competencies became more visible by working together, but frustration was also expressed due to different levels of engagement in the health-promotion practice.

Conclusions

Health-promotion practice can be normalized as routine work in PHC with targeted support but requires tailored strategies that rely on existing group dynamics and the manager’s role. To create motivation for providing health promotion, inter-professional collaboration is a key factor that ensures shared ownership of the implementation intervention.

BACKGROUND: The Normalization Process Theory (NPT) is increasingly used for evaluating and understanding implementation processes of complex care interventions. One key tool for applying the NPT in research and practice is the NoMAD questionnaire, which offers a structured approach to examination of the four constructs that according to the NPT are central in implementation and normalisation processes. We aimed to evaluate the psychometric properties of the Swedish version S-NoMAD.

METHODS: Secondary analysis was performed on pooled S-NoMAD survey data from six implementation studies in different health and social care contexts. The NPT factor structure was tested by confirmatory factor analysis (CFA). Internal construct reliability was tested using Cronbach's alpha. Validity was confirmed by assessing the fit of the CFA using the fit measures Comparative Fit Index, Tucker-Lewis Index, root mean square error of approximation and standardised root mean square residual. Pearson correlations amongst the latent construct and general questions about the intervention were calculated.

RESULTS: The estimation results of the CFA indicate that the four-factor model implied by the NPT fits the data reasonably well. The factor loadings are of good sizes and the fit indices do not imply a mis-specified model. A good internal construct validity, indicated by a good model fit to the NPT four-construct model and acceptable to good internal reliability, was shown. External validity was also demonstrated.

CONCLUSIONS: The CFA results indicate that the S-NoMAD has good psychometric properties for capturing perceptions of people involved in various Swedish implementation studies conducted in both health and social care contexts, demonstrating its general applicability. They show that the S-NoMAD, unlike the majority of instruments for evaluation of implementation processes, is not context- and intervention-specific. The findings highlight the utility of the S-NoMAD and show that it meets some important criteria for pragmatic measures. Further studies are warranted on different interventions implemented in diverse contexts regarding the meaning of the magnitude of the NoMAD scores in order to clarify its potential value as a tool for assessment of implementation strategies and on psychometric properties beyond construct validity and internal construct reliability, for example on test-retest reliability and longitudinal studies focusing on responsiveness.

BACKGROUND: Despite legislative support, PCC is not systematically practiced. An online facilitation training program targeting healthcare staff was developed in Sweden. This study aims to explore the acceptability, appropriateness, and feasibility of this facilitation training program, designed to support PCC implementation.

METHODS: This interview study evaluates the FaciLitating Implementation of Person-centered care (FLIP) training program according to the implementation outcomes acceptability, appropriateness, and feasibility, using deductive qualitative content analysis. FLIP integrates the Building Implementation Capacity for Facilitation (BIC-F), which focuses on behavioral change, and PCC principles. FLIP included workshops and supervision sessions held online, led by external facilitators. Between these meetings, the FLIP participants worked with implementation plans in co-creation with their colleagues. Five healthcare units, with different healthcare contexts, in Sweden, participated over 12 weeks with two healthcare staff assigned the role as internal facilitators per unit, selected and supported by their managers. All internal facilitators, managers, and external facilitators were invited to participate in evaluating FLIP. A total of 17 participants, eight internal facilitators, five managers, and four external facilitators were interviewed in semi-structured individual and group interviews.

RESULTS: FLIP was generally accepted among all participants, due to its emphasis on PCC, comprehensive content, and clear structure, as well as its blend of training, collaboration, and mutual support. Nevertheless, the acceptability was negatively affected by low attendance, low engagement due to the online format, and initial struggles with the systematic implementation model. The systematic implementation model used in FLIP was perceived as appropriate for implementing PCC in clinical practice; however, the training on PCC was viewed as insufficient, leading to challenges operationalizing PCC elements. The participants' perceptions of FLIP's feasibility varied; while delivery was manageable, busy schedules and technical disruptions negatively affected attendance and engagement.

CONCLUSIONS: Becoming a facilitator capable of supporting the implementation of PCC is demanding and requires an understanding of both implementation and PCC. The BIC-F model was found to be accepted and appropriate, but operationalizing PCC requires more focus. Managerial support is needed to increase feasibility. Further research is required to evaluate whether facilitation skills can be trained online for large-scale PCC implementation.

BACKGROUND: Evidence-based healthcare recommendations exist for tobacco use, harmful alcohol consumption, low physical activity, and poor diet. However, the uptake of these recommendations in Swedish primary healthcare is poor, and the potential benefits for patients are not fully realized. Our aim was to evaluate the effect (i.e. the uptake) of a 12-month multifaceted implementation strategy to achieve a more health-promoting practice. We hypothesized that primary healthcare centers receiving this strategy would increase and sustain their health-promotion practices to a significantly greater extent than control centers, from baseline to the 6-month follow-up.

METHODS: In a non-randomized parallel group study, 5 intervention centers and 5 matched control centers were compared regarding health-promotion activities delivered in relation to visits to each center. The intervention centers received a multifaceted implementation strategy over at least 12 months based on established strategies, the Astrakan model of leading change, and findings from pre-implementation studies. The main strategies were: using external and internal facilitators to combine bottom-up and top-down perspectives, and emphasizing leadership responsibility for change. Medical record data on health-promotion activities, including prescribed physical activity and use of lifestyle screening forms, were collected monthly for 2 years: 6 months before and after implementation, and during the implementation phase. The implementation strategy effect was estimated using generalized linear mixed models.

RESULTS: During the 12-month implementation phase, the intervention and control sites had 135 002 and 160 987 healthcare visits, respectively; conducted 8839 and 6171 health-promotion activities, respectively; and administered 2423 and 282 lifestyle screening forms, respectively. A statistically significant higher relative uptake rate of health-promotion activities was found in intervention sites compared to control sites after the implementation period compared to before. The effect increased during the active phase, with the intervention sites having on average 1.07 and 2.0 times the uptake rate of the control sites at 1 and 12 months, respectively; this effect was largely maintained during the 6-month post-intervention phase. A significant absolute effect, in terms of difference in predicted uptake per 1000 visits, was evident 7 months into the implementation phase.

CONCLUSION: This multi-faceted implementation strategy was successful in achieving a more health-promoting practice. (ClinicalTrials.gov ref: NCT04 799,860, 03/04/2021, https://clinicaltrials.gov/study/NCT04799860 ).

TRIAL REGISTRATION: This study is part of the Act in Time project, registered at ClinicalTrials.gov on 4 March 2021 (ref: NCT04 799,860).

BACKGROUND: Appropriately and comprehensive applying implementation frameworks is one of the key challenges in implementation science resulting in increased use of multiple implementation frameworks within projects. This is particularly true for frameworks such as PARIHS/i-PARIHS. Therefore, this systematic review aimed to examine if and why the PARIHS/i-PARIHS framework has been applied in research with other implementation frameworks.

METHODS: We searched six databases from 2016 (the year following i-PARIHS' publication) to April 2024 and supplemented this with a citation search of the seminal i-PARIHS paper. We included studies that 1) were peer-reviewed with a protocol or empirical study design, 2) have applied the PARIHS or i-PARIHS framework for implementation planning, delivery, analysis, or evaluation and 3) also used at least one other implementation framework. Descriptive statistics were conducted to report on study characteristics and frequency for each implementation framework used with PARIHS/i-PARIHS. A qualitative, content analysis was used to analyse the answers to open-ended extraction questions.

RESULTS: Thirty-six articles met criteria for inclusion and included 16 protocols and 20 empirical articles (twelve intervention and eight cross-sectional studies). Thirty-four of the studies used one additional implementation framework and two studies used two additional implementation frameworks. In total, nine implementation frameworks were applied with PARIHS/i-PARIHS, including: 1) RE-AIM, 2) CFIR, 3) NPT, 4) REP, 5) TDF, 6), DSF, 7) KTA, 8) Stetler's Model, and 9) SIF. Thirty-four reported a rationale for using PARIHS/i-PARIHS and 34 reported a rationale for using the other implementation framework. Only eleven reported a rationale for using more than one implementation framework. Only three reported strengths of combining implementation frameworks.

CONCLUSIONS: Overall, this review identified that implementation researchers are using PARIHS/i-PARIHS in combination with other implementation frameworks and providing little to no rationale for why. Use of multiple implementation frameworks without detailed rationales compromises our ability to evaluate mechanisms of effectiveness. Implementation researchers and practitioners need to be more explicit about their framework selection, detailing the complementary strengths of the frameworks that are being used in combination, including why using one is not sufficient.

TRIAL REGISTRATION: This systematic review was registered with PROSPERO: ID: 392147.

Background: The Family Talk Intervention (FTI) is a psychosocial intervention supporting families where a family member has palliative care needs. This study aimed to evaluate how the Family Talk Intervention (FTI) was implemented over time from the perspective of hospital social workers (HSWs) in their everyday clinical practice among families with a severely ill parent or child in need of palliative care.

Methods: HSWs (n = 21) working in adult and children's care completed a 10-day education where they were trained to use FTI. The education was part of a multifaced implementation strategy involving educational outreach visits, facilitation, clinical implementation meetings, and audit and feedback. The HSWs were then expected to use FTI in their clinical practice to support families with dependent children. To assess if and how FTI was integrated into their daily practice, they were also asked to complete the Swedish version of the Normalization Process Theory Measure (S-NoMAD) on three occasions: on completion of the FTI-education, six months later, and one year later. For the longitudinal analysis of data, Friedman's test was used.

Results: The HSWs rated the use of FTI high after completing the FTI-education, indicating a positive attitude towards FTI. In the longitudinal analysis, statistically significant changes were seen for two questions in S-NoMAD, where the HSWs' ratings showed that the FTI became more familiar and normalized over time. Generally, the HSWs' ratings of S-NoMAD's main constructs were high and stable over time, indicating a positive view of FTI and its implementation. However, for the single questions, the ratings were slightly more negative to some contextual aspects, such as managerial support and resources.

Conclusion: As results showed, HSW mainly rated different aspects of the implementation process as positive, both from the beginning, but also over time. Therefore, the intervention could be judged to have been implemented as a tool to support families when a parent or a child is severely ill. Contextual factors, involving managerial support and resources were rated lower, indicating the importance of those aspects when introducing interventions into healthcare. The result also indicates that the multifaced implementation strategy supported the HSW's everyday clinical practice.

Clinical Trial Registration: clinicaltrials, nr, identifier (NCT05365919; 2022-03-04 and; NCT05020158 2021-05-11).

OBJECTIVE: 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.

DESIGN: 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.

SETTING AND PARTICIPANTS: 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.

RESULTS: 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.

CONCLUSION: 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.

TRIAL REGISTRATION: ClinicalTrials.gov NCT04799860.

Decommissioning programmes pose a substantial risk of failure compared to other change processes in healthcare. A better understanding of the challenges associated with change processes initiated by resource scarcity faced by healthcare managers is crucial. This study describes and compares department and unit managers' experiences during the implementation of a large-scale decommissioning programme in a Swedish region. A survey was developed and a cross-sectional study was performed, measuring 172 healthcare managers' experiences of (1) the region's leadership, (2) their own participation and (3) their own commitment and responsibility during the implementation of the decommissioning programme. Respondents were 50 department managers and 122 unit managers (93% and 58% response rate, respectively). There was a significant difference between department and unit managers in their experiences of the region's leadership and their own participation in the decommissioning programme. Unit managers were more dissatisfied with the way it developed compared to department managers. For example, unit managers reported a lower level of leadership support, incentives to participate, and that their knowledge and skills were not fully utilised. Involvement of unit managers in a more fruitful way might enhance the results of decommissioning programmes. This study highlights a key actor in this context: the unit manager.

BACKGROUND: The growing concern about a dwindling healthcare workforce, exacerbated by demographic changes, calls for innovative solutions. One viable approach involves implementing new professional roles and restructuring existing healthcare teams within hospital care units.

OBJECTIVES: To evaluate the implementation of an innovative task-shifting concept, care-related services (CRS), from the managers' perspective in somatic care units across the hospitals in a region in Sweden.

METHODS: The qualitative study was conducted in 2022, after the implementation of CRS. Individual interviews were conducted with 24 key stakeholders, including 14 care unit managers, six CRS managers, and four process managers. A qualitative content analysis was performed, utilizing the Consolidated Framework of Implementation Research (CFIR).

RESULTS: The implementation of CRS involved collaboration between care unit managers, CRS managers, and project managers, alongside CRS staff, registered nurses (RNs), and licensed vocational nurses (LVNs). In particular, their roles encompassed defining boundaries, establishing routines, and managing personnel. Throughout the implementation process, challenges emerged, stemming from undefined goals, difficulties in recruiting qualified CRS staff, and issues associated with seamlessly integrating CRS into existing work routines. These challenges arose due to a constrained timeframe, widespread team apprehension, shortcomings in the training of CRS staff, unclear task allocation, and an increased workload for care unit managers. Factors associated with successful CRS implementation included effective cooperation among managers and an open-minded approach.

CONCLUSIONS: Our findings highlight the crucial role of clear communication, effective recruitment, integration of CRS staff, clarification of roles, responsibilities, and defined goals for successful CRS implementation.