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Table 4 Results in terms of linked interventions, underlying theories and responsibilities based on implementation criteria according to CFIR domains/constructs

From: Towards a nationwide implementation of a standardized nutrition and dietetics terminology in clinical practice: a pre-implementation focus group study including a pretest and using the consolidated framework for implementation research

CFIR DomainCFIR ConstructImplementation strategy criteria (points to consider based on focus groups)Intervention (based on focus groups and literature [39, 40, 43, 44, 60,61,62])Underlying theory [27, 39, 40]Responsibility
Intervention characteristicsEvidence Strength & QualityStarting implementation with pilot institutions.
Adducing ICF-Dietetics field studies and other examples (e.g. nursing language).
Conduct a Pilot study Research Institution
Relative AdvantageConveying the benefits of ICF-Dietetics.Provide information: on the ICF-Dietetics its advantages and disadvantages adapted to different learning stylesCognitive theory on learningAssociation of Dietitians
(disadvantage)Considering the drawbacks of using the ICF in form of a professional-specific terminology.
Avoiding over-categorizing.
Provide information for other professional groups
Refine application concept to improve attractiveness
Theory on organizational learning,
Theory on learning
Implementation leader1
Developer of the concept2
(advantage and disadvantage)To consider if the ICF model should be introduced in education and practice.Refine application concept to improve attractivenessTheory on learningDeveloper of the concept
AdaptabilityThe application concept and the ICF-Dietetics (granularity) have to be adaptable to different settings and workflows in professional practice.
In principle, the ICF / ICF-Dietetics offers this possibility.
Provide information: on the possibility for adaptability to different settings adapted to different learning styles
Enable self-regulation to adapt application to individual needs
Cognitive theory on learning
Behavior, observational learning
Association of Dietitians
Developer of the concept
TrialabilityProviding examples for practice purposes before implementation.Start with practical-related interactive workshops before implementationSocial cognitive theoryAssociation of Dietitians
ComplexityBeing aware of barriers of complexity.
It takes extensive experience regarding the assignment to appropriate ICF-Dietetics categories, the use of qualifiers, as well as the assignment to environmental factors and personal factors.
Start with practical-related interactive workshops before implementation
Provide training to change group processes
Social cognitive theory
Theory on team effectiveness, group decisions
Association of Dietitians (ICF trainers)
Implementation leader
  Provide skills training and feedback on performanceCognitive theory on learningImplementation leader
  Enable self-regulation to adapt application to individual needsBehavior, observational learningDeveloper of the concept
 Putting codes in the background.Refine application concept to improve attractivenessTheory on learningDeveloper of the concept
 Recognizing the large number of ICF-Dietetics categories as a major barrier. Being aware of the need to develop a nutrition and dietetics-related Core Set.Refine application concept to improve attractiveness: Develop a nutrition and dietetics-related Core SetTheory on learningDeveloper of the concept or Researcher
 Being aware of the barrier of initial effort.Define individual goals for changeMotivational theoriesImplementation leader
 Taking into account and communicate the need of additional time especially, at the beginning.Provide training to change group processesTheory on team effectiveness, group decisionsImplementation leader
 Perceived incompleteness of the ICF-Dietetics categories may come through lack of practice and experience in the use of the new language.Involve opinion leaders or professional peers (educational outreach)Theories of planned behavior and social comparisonImplementation leader
Design Quality & PackagingThere is a need for an intelligent search function, and the integration of the ICF-Dietetics in electronic health record systems.Incorporate the ICF-Dietetics into existing information systems for coding purposesTheory on organizational learningImplementation leader or institution leadership
 The application concept has to be well designed and clear. Clarifying questions, such as; what should be documented? What should be done with the documentation?Refine application concept to improve attractivenessTheory on learningDeveloper of the concept
 Beginning with a small Core Set, that should be extensible.Refine application concept to improve attractiveness: develop a nutrition and dietetics-related Core SetTheory on learningDeveloper of the concept
 Beginning with a simplified application.Refine application concept to improve attractivenessTheory on learningDeveloper of the concept
 There is a need for a table of contents.Refine application concept to improve attractivenessTheory on learningDeveloper of the concept
 There is a need for a revision of the ICF-Dietetics (in cooperation with the proprietors of the original ICF-Dietetics).Refine application concept to improve attractiveness: Revise the ICF-DieteticsTheory on learningDeveloper of the concept
 There is a need for a balance between completeness and not confusing.Refine application concept to improve attractiveness: Revise the ICF-DieteticsTheory on learningDeveloper of the concept
Outer settingNeeds & Resources of Those Served by the OrganizationFocusing on patient orientation and patient goals and continuing of care. Recognizing that the focus only on interventions goals, that has set by health professionals could be a great barrier in terms of patient-centered care.Take care of patient focused goals and satisfactionTheory on quality managementDietitians
Peer PressureConveying the awareness of the necessity to ensure evidence in the future.Provide general information: to ensure evidenceCognitive theory on learningAssociation of Dietitians
External Policy & IncentivesThe implementation of the ICF-Dietetics nation-wide should be supported by politics and legal regulation.Influence decision makers, build political supportTheory on agenda buildingAssociation of Dietitians
 Presentation of the concept at congresses and other health care events.Influence decision makers, build stakeholder supportTheory on agenda buildingAssociation of Dietitians
 The recently started realization of Primary Health Care Centers could be facilitate the implementation of a multidisciplinary applicable terminology.Influence decision makers, build public supportTheory on agenda buildingAssociation of Dietitians
 Publishing best practice examples.Provide information of best practice examplesCognitive theory on learningAssociation of Dietitians
Inner settingNetworks & CommunicationsIntegrating and inform other health care professional and aiming a common solution.Make better use of information technology Provide information for other professional groupsTheory on organizational learning Theory on integrated careImplementation leader or institution leadership
Tension for ChangeNecessity for implementation have to come from leadership of institutions.Provide specific information on the advantages of the ICF-Dietetics for managers and the leadership of the institutionTheories on persuasion and leadershipImplementation leader
 Tension for change has to be seen and build up within the professional group.Implement continuous improvement activitiesTheories on quality managementImplementation leader or institution leadership
CompatibilityICF-Dietetics needs to be adapted to the dietetic care process, not the other way around.
The ICF is not an assessment, but for developing assessments for functioning.
Implement continuous improvement activitiesTheories on quality managementImplementation leader or institution leadership
  Create teams/collaborative for improvementTheories on quality managementImplementation leader or institution leadership
  Recruit and train leaders to integrate or establish a continuous improvement program in dietetics careTheories on quality managementImplementation leader or institution leadership
  Enable self-regulation to adapt application to individual needsBehavior, observational learningDeveloper of the concept
Relative PriorityConducting needs assessment before implementation, e.g., about the perceived importance of implementing a standardized terminology in dietetics.Not necessary: evaluations have already been conducted  
Organizational Incentives & RewardsThere should be a defined compensation of the additional required time and the recognition from the leadership of the institutions.Define compensation of the additional required time and the recognition from the leadership of the institutionsReimbursement theoriesImplementation leader or institution leadership
Leadership EngagementManagement and leadership of institutions (e.g. the quality assurance departments) have to take responsibility for the implementation.Provide specific information on the advantages of the ICF-Dietetics for managers and the leadership of the institutionTheories on persuasion and leadershipImplementation leader
Available ResourcesResources, especially time and/or additional human resources, have to be clarified in advance.Provide information about additional resources and clarify them in advanceTheories of LeadershipImplementation leader
Characteristics of individualKnowledge & Beliefs about the InnovationConveying clear usability of the application concept and the ICF-Dietetics, e.g. how it works and which steps and ICF-Dietetics categories should be documented.Provide general information
Involve opinion leaders or professional peers (educational outreach)
Cognitive theory on learning
Motivational theories
Association of Dietitians
Implementation leader
 Conveying the usability of the ICF-Dietetics within a multiprofessional approach, and conveying that not everything is new, but has already been applied in dietetic practice.Provide general information
Involve opinion leaders or professional peers (educational outreach)
Cognitive theory on learning
Motivational theories
Association of Dietitians
Implementation leader
Other Personal AttributesMotivating dietitians in order to prevent resistance, e.g. motivate them to overcome the first needed effort for a higher aim.Define individual goals for changeMotivational theoriesImplementation leader
Process of implementationPlanningEvaluate what is taught at universities regarding standardized terminologies in general and about the ICF in particular.Not necessary: all program directors of universities participated in the focus groups  
 Planning the implementation stepwise (e.g., firstly, standardizing the assessments and the dietetics diagnosis, then adopting intervention goals with pre-defined goal lists in terms of ICF-Dietetics categories).Apply intervention stepwise according to the “stage” of changeStages-of-Change TheoriesDietitians
 Standardizing the dietetic care process that is taught in universities.Standardize teaching plans of dietetics universitiesTheory on learningDirectors of universities
 Further validation of the ICF-Dietetics should be done in the ongoing process.Refine application concept to improve attractiveness: Revise the ICF-DieteticsTheory on learningDietitians and developer of the concept
EngagingOffering of trainings and ICF workshops for practicing dietitians, supervisors for interns and teachers.Start with practical-related interactive workshops before implementation
Provide continuous trainings
Social cognitive theory
Theory of Total Quality Management
Association of Dietitians
Implementation leader
 Developing practice-oriented standardized training material.Provide printed educational material, e.g. a manual of the dietetics care process and the use of the ICF-DieteticsTheory on learningAssociation of Dietitians
Opinion LeadersInstitutions need a person as an opinion leader.Involve opinion leaders or professional peers (educational outreach)Theories of planned behavior and social comparisonImplementation leader
(Key Stakeholders) 3Addressing different settings and work experience of dietitians, such as, students, freelancers and employees, those they just finished their education and those who have been in practice for many years.Provide information on the ICF-Dietetics for adaptability to different settings adapt to different learning stylesCognitive theory on learningAssociation of Dietitians
  1. 1The implementation leader is someone who is the champion on each facility usually the leading dietitian
  2. 2The developer of the concept is the researcher who has develop the application concept to integrate the ICF-dietetics in the Austrian dietetic care process
  3. 3The construct key stakeholder is described in the CFIR codebook however not mentioned as separate CFIR construct by Damschroder et al. [38]