Utilising Practice Development and the PARIHS Framework to Implement the Liverpool Care Pathway

<p>The LCP is an evidence-based integrated care pathway that provides guidance to generic health care professionals to deliver best practice end-of-life care. My role as the LCP Project Coordinator in a District Health Board in New Zealand is central to the exploration of this process of implementing practice change. Working with clinicians to advance effective care and management of patients during the process of dying in an acute hospital setting requires not only knowledge and understanding of the clinical pathway and evidence supporting best practice, but also careful working with cultural and contextual change. This paper descriptively addresses the bases of both components, and provides a case example of the development. Working with health care professionals to bring about practice change is complex and challenging. Successful implementation of evidence in practice is dependant not only on the strength and nature of the evidence, but also the context and models of facilitation. Practice development (PD) methodology informs the realities and complexities of practice change and of achieving sustainable development. The 'Promoting Action in Research Implementation in Health Services' (PARIHS) framework identifies the interplay and interdependence of factors that resonate with the reality of the complexity of practice change in relation to the evidence and best practice for particular clinical contexts. Highlighting PD processes and the relevance of the PARIHS framework alongside real-time practice change will continue to stimulate recognition of change and development complexities and bring consideration of these as robust methods for working between the theory and implementation of evidence in practice.</p>

Utilising Practice Development and the PARIHS Framework to Implement the Liverpool Care Pathway

<p>The LCP is an evidence-based integrated care pathway that provides guidance to generic health care professionals to deliver best practice end-of-life care. My role as the LCP Project Coordinator in a District Health Board in New Zealand is central to the exploration of this process of implementing practice change. Working with clinicians to advance effective care and management of patients during the process of dying in an acute hospital setting requires not only knowledge and understanding of the clinical pathway and evidence supporting best practice, but also careful working with cultural and contextual change. This paper descriptively addresses the bases of both components, and provides a case example of the development. Working with health care professionals to bring about practice change is complex and challenging. Successful implementation of evidence in practice is dependant not only on the strength and nature of the evidence, but also the context and models of facilitation. Practice development (PD) methodology informs the realities and complexities of practice change and of achieving sustainable development. The 'Promoting Action in Research Implementation in Health Services' (PARIHS) framework identifies the interplay and interdependence of factors that resonate with the reality of the complexity of practice change in relation to the evidence and best practice for particular clinical contexts. Highlighting PD processes and the relevance of the PARIHS framework alongside real-time practice change will continue to stimulate recognition of change and development complexities and bring consideration of these as robust methods for working between the theory and implementation of evidence in practice.</p>

Implementing Specialized Vestibular Physiotherapy in An Emergency Department: A Process Evaluation

Background: Dizziness and vertigo-like symptoms, often caused by common peripheral vestibular disorders such as Benign Paroxysmal Positional Vertigo (BPPV), may have a significant detrimental impact on function and quality of life. The impact of these symptoms often result in Emergency Department (ED) presentations. Evidence based clinical practice guidelines strongly recommend the use of physical assessment and treatment maneuvers for the assessment, diagnosis and treatment of these symptoms. The aim of this study was to evaluate the process of implementing specialized vestibular physiotherapy in an emergency department, from the clinician perspective.Methods: This implementation study utilized a retrospective mixed methods process evaluation to understand how specialized vestibular physiotherapy operated in an Australian emergency department. The PARiHS Framework was embedded within the methodology and analytical approach of the study, to ensure a comprehensive approach which was closely aligned to implementation science. Nine clinicians retrospectively completed the Organizational Readiness for Change Assessment (ORCA), Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM) and Feasibility of Intervention Measure (FIM). Seven clinicians also participate in a focus group or interview.Results: A range of barriers and facilitators to the implementation process were identified by participants, some of which spanned multiple domains of the PARiHS framework. Relationships with service leaders, champions and medical staff were found to be a key facilitator to implementation, along with a generally held perception that specialized vestibular physiotherapy was acceptable and feasible. The main barrier identified was a lack of capacity to deliver and support this innovation, both within the physiotherapy workforce and the broader multidisciplinary team.Conclusions: This study demonstrates the process of implementation of a specialized vestibular physiotherapy team in an ED setting was generally well received by clinicians, but also involved some challenges and barriers. Services looking to implement specialized vestibular physiotherapy in the ED may refer to the recommendations arising from the findings of this study to guide their approach to innovation.

The Development of a Community-based COVID-19 Public Health Intervention in Rural Ghana

Background: The Promoting Action on Research Implementation in Health Services (PARIHS) framework was utilized to design an evidence-based practice, Cocoa360’s COVID Preparedness & Outbreak Prevention Plan (CoCoPOPP), for rural communities in Ghana. Through participatory academic-community team discussion, interactive dissemination, systematic review of evidence about community-based interventions during Ebola, HIV/AIDS, and Influenza outbreaks and effective engagement with local and national stakeholders, CoCoPOPP was developed to be consistent with the PARIHS framework. Methods: Applying the three core elements of the PARIHS framework (evidence, context, and facilitation), the designers developed orientation, logistic needs and planning, and social mobilization. Components of CoCoPOPP also included participant recruitment and training, communication, research, monitoring & evaluation plan, execution, technical assistance, and facilitation. Results: This intervention achieved three (3) main aims: (1) meet a pressing health need during the COVID-19 pandemic in local underserved settings, (2) ensure that the strategy is informed by high-quality evidence from similar interventions in past outbreaks, and (3) evaluate and learn from research on interventions to garner data. Beyond the impact on health outcomes and healthcare services utilization, CoCoPOPP sought to garner data for organizational use and to share insights on pandemic management and control with the Ghanaian government and the broader global health community. Conclusion: The use of evidence-based public health framework, PARIHS, renders CoCoPOPP a replicable community-based model that can be implemented in other rural communities in Ghana and other Sub-Saharan African counties with similar cultural settings.

Fluctuations in barriers to medication treatment for opioid use disorder prescribing over the course of a one-year external facilitation intervention

Background The Veterans Health Administration (VHA) is invested in expanding access to medication treatment for opioid use disorder (MOUD) to save lives. Access varies across VHA facilities and, thus, requires implementation strategies to promote system-wide adoption of MOUD. We conducted a 12-month study employing external facilitation that targeted MOUD treatment among low-adopting VHA facilities. In this study, we sought to evaluate the patterns of perceived barriers over 1 year of external implementation facilitation using the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Methods We randomly selected eight VHA facilities from the bottom quartile of the proportion of Veterans with an OUD diagnosis receiving MOUD (< 21%). The 1-year external implementation intervention included developmental evaluation to tailor the facilitation, an on-site visit, and monthly facilitation calls. Facilitators recorded detailed notes for each call on a structured template. Qualitative data was analyzed by coding and mapping barriers to the constructs in the i-PARIHS framework (Innovation, Recipients, Context). We identified emerging themes within each construct by month. Results Barriers related to the Innovation, such as provider perception of the need for MOUD in their setting, were minimal throughout the 12-month study. Barriers related to Recipients were predominant and fluctuated over time. Recipient barriers were common during the initial months when providers did not have the training and waivers necessary to prescribe MOUD. Once additional providers (Recipients) were trained and waivered to prescribe MOUD, Recipient barriers dropped and then resurfaced as the facilities worked to expand MOUD prescribing to other clinics. Context barriers, such as restrictions on which clinics could prescribe MOUD and fragmented communication across clinics regarding the management of patients receiving MOUD, emerged more prominently in the middle of the study. Conclusions VHA facilities participating in 12-month external facilitation interventions experienced fluctuations in barriers to MOUD prescribing with contextual barriers emerging after a facilitated reduction in recipient- level barriers. Adoption of MOUD prescribing in low-adopting VHA facilities requires continual reassessment, monitoring, and readjustment of implementation strategies over time to meet challenges. Although i-PARIHS was useful in categorizing most barriers, the lack of conceptual clarity was a concern for some constructs.

Evaluating factors that influenced the successful implementation of an evidence-based neonatal care intervention in Chinese hospitals using the PARIHS framework

Background Evidence based interventions (EBIs) can improve patient care and outcomes. Understanding the process for successfully introducing and implementing EBIs can inform effective roll-out and scale up. The Promoting Action on Research Implementation in Health Services (PARIHS) framework can be used to evaluate and guide the introduction and implementation of EBIs. To gain an understanding of the utility of the PARIHS framework in China and investigate how important each of its constructs (evidence, context and facilitation) and sub-elements are perceived to be to successful implementation of EBIs in a Chinese setting, we used the framework to assess the implementation of an evidence-based neonatal intervention (kangaroo mother care, KMC) recently introduced in selected Chinese hospitals. Method We conducted clinical observations and semi-structured interviews with 10 physicians and 18 nurses in five tertiary hospitals implementing KMC. Interview questions were organized around issues including knowledge and beliefs, resources, culture, implementation readiness and climate. We used directed content analysis to analyze the interview transcript, amending the PARIHS framework to incorporate emerging sub-themes. We also rated the constructs and sub-elements on a continuum from “low (weak)”, “moderate” or “high (strong)” highlighting the ones considered most influential for hospital level implementation by study participants. Results Our finding suggest that clinical experience, culture, leadership, evaluation, and facilitation are highly influential sub-elements for EBI implementation in China. External evidence had a moderate impact, especially in the initial awareness raising stages of implementation and resources were also considered to be of moderate importance, although this may change as implementation progresses. Patient experience was not seen as a driver for implementation at hospital level. Conclusion The PHARIS framework can be a useful tool for planning and evaluating EBI implementation in China. However, it’s sub-elements should be assessed and adapted to the implementation setting.

Can National Oral Health Policy Reform Be Successfully Translated into Practice and Reduce the Burden of Disease in Australia?

BACKGROUND: The discrepancy between policy makers decisions, current research and clinical practice is of huge significance to the health industry and the Australian community. AIM: Evaluate of translational research frameworks and policy formulation within the Australian oral health context. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a focused systematic search was conducted using an electronic search of the CINAHL database, including Medline, Cochrane and Scopus. A combination of key terms including “oral health”, “prevention’’, 'translational research’, “public policy”, were used for the searches. RESULTS: The initial literature search found 561 abstracts in CINAHL database. Review against the inclusion criteria and removal of duplicates yielded 129 abstracts; further reviewed against the inclusion criteria resulted in 35 included in the review of translational research models. Across the 35 papers 8 different frameworks for translation of research evidence into policy and practice were utilised across the literature. The results reported in this studies show that the PARiHS framework depicts successful translation as a function of the relationship between evidence, context and facilitation. These interplays of elements are particularly of relevance to oral health due to the complexity of the sector. Context (current and historical) and facilitation (including governance/regulation) are the foundational drivers of successful implantation of evidence into practice. CONCLUSION: The PARiHS framework for implementing research into practice is an appropriate model for oral health. Universal access is a feasible step in addressing the current inequities of access to oral health care.

Sustaining implementation facilitation: a model for facilitator resilience

Background Implementation facilitators enable healthcare staff to effectively implement change, yet little is known about their affective (e.g., emotional, mental, physical) experiences of facilitation. We propose an expansion to the Integrated Promoting Action on Research in Health Services (i-PARIHS) framework that introduces facilitation intensity and facilitator resilience to better assess facilitators’ affective experiences. Methods We used an instrumental case study and facilitator data (logged reflections and debrief session notes) from the Coordination Toolkit and Coaching initiative to conceptualize facilitation intensity and facilitator resilience and to better understand the psychological impact of the facilitation process on facilitator effectiveness and implementation success. Results We define facilitation intensity as both the quantitative and/or qualitative measure of the volume of tasks and activities needed to engage and motivate recipients in implementation, and the psychological impact on the facilitator of conducting facilitation tasks and activities. We define facilitator resilience as the ability to cope with and adapt to the complexities of facilitation in order to effectively engage and motivate staff, while nurturing and sustaining hope, self-efficacy, and adaptive coping behaviors in oneself. Conclusions Facilitators’ affective experience may help to identify potential relationships between the facilitation factors we propose (facilitation intensity and facilitator resilience). Future studies should test ways of reliably measuring facilitation intensity and facilitator resilience and specify their relationships in greater detail. By supporting facilitator resilience, healthcare delivery systems may help sustain the skilled facilitator workforce necessary for continued practice improvement. Trial registration The project was registered with ClinicalTrials.gov (NCT03063294) on February 24, 2017.

Using PARIHS framework to design a community-based COVID-19 intervention in rural Ghana

This study utilized the Promoting Action on Research Implementation in Health Services (PARIHS) framework to guide the design of the evidence-based practice, COVID Preparedness & Outbreak Prevention Plan (CoCoPOPP) for rural communities in Ghana. Through a participatory academic-community team discussion, interactive dissemination, review of evidence about community-based interventions during Ebola, HIV/AIDS, and Influenza outbreaks via snowball sampling, continuous discourse within the design team, feedback from other local stakeholders and national experts, the evidence-based intervention was developed consistent with the PARIHS framework. By applying the three core elements of the PARIHS framework (that is, evidence, context and facilitation), the study developed orientation, logistic needs and planning as well as social mobilization. The components also included participants recruitment and training, communication, research and M&E plan, execution and technical assistance and facilitation with three overall aims: (1) meet a pressing health need during the COVID-19 pandemic in local underserved settings, (2) ensure that the strategy is informed by high-quality evidence from similar interventions in past outbreaks and (3) evaluate and learn from research on interventions to garner data for organizational use and to share insights on pandemic management and control with the Ghanaian government, wider global health and education community. Hence, CoCoPOPP can be implemented across other rural communities in Ghana and beyond, particularly in other Sub-Saharan African countries with similar cultural settings.