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Table 4 Post Implementation factors identified by clinician and parent survey and technical assistance logs

From: Introducing a MAP for adherence care in the paediatric cystic fibrosis clinic: a multiple methods implementation study

CFIR constructs

Factors identified by stakeholders

Valence

Description/ Quote

Inner Setting

Implementation climate

Compatibility

(U)

The pre-implementation co-design and facilitation supported compatibility between the local adherence protocol and local processes. However, modifications to the local adherence protocol continued throughout the implementation phase, into the last week. Clinicians reported that a preference for components to be embedded with existing systems to reduce double handling of information (such as entry into electronic records and written treatment plan)

“Improve by integrating to current system with excel spreadsheet at front desk. Streamline to make more efficient” (Clinician survey, post-implementation)

Readiness for intervention

Available Resources

(−)

Clinicians identified time, available electronic systems, clinic nurse resourcing as barriers to implementation.

“What gets in the way?” “Time pressure of clinic and not even time when in with patients/ families.” (Clinician survey, post-implementation).

“Any extra work is difficult.” (Clinician survey, post-implementation)

Networks and Communication

Co-ordination

(U)

Completion of the adherence protocol required the physician, physiotherapy, occupational therapist, dietician, nurse, social worker to all review the family within their annual review appointment. Through auditing, it was observed that elements of the protocol were not completed when reviewed in chart audit due to family leaving before being seen by all team members. Clinicians acknowledged that whole team input was impactful on perceived acceptability of tool.

“If [the written treatment plan is] not used consistently with all staff then the efficacy of tool is significantly diminished” (Clinician survey, post-implementation)

It was observed that clinic nurses assumed a coordinator role to support completion by all team members, which positively impacted implementation.

 

Formal communication

(−)

Reduced attendance at team meetings impacted diffusion of training information and modifications made to processes. It was a challenge to ensure the awareness of whole team.

Process

Engaging

Getting the whole team on board

(−)

End survey results of clinicians and parents showed varying levels of awareness around adherence protocol components. An implementation team (consisting of nursing, allied health and research team representatives) was formed during implementation phase to support diffusion of information and to support ongoing protocol facilitation.

Outer Setting

Needs and Resources of those served by the organisations

Ability to individualise care

(+)

Clinician acceptability scores consistently suggested that the local adherence protocol components were perceived to be high value for families.

“Very useful and family centred.” (Clinician survey, post-implementation),

“It’s good for parents to know who needs to see them.” (Clinician survey, post-implementation)

Parents reported that they felt the components were helpful but reported that inconsistent use was a frustration.

“I saw this on e-mail (parent newsletter), if I’m aware that I can use it at clinic that would be great. Didn’t ask me today.” (Parent survey, post-implementation)

Characteristics of Individuals

Individual stage of change/ knowledge

(−)

Clinicians reported that learning new systems, forgetfulness and new habit formation impacted upon individual change.

“Forgetting to use it as it is a new process. Just requires longer use to get used to it” (Clinician survey)

Individuals identified gaps in their knowledge and understanding of processes, comments suggest this was linked to ongoing process modifications.

“It’s just sometimes difficult to know where it’s kept (storage of written treatment plan). Needs to be consistent.” (Clinician survey, post-implementation)

Intervention Characteristics

Quality and packaging

Digital platforms and associated resources

(U)

Unfamiliar technology platforms were introduced to support the requirements of digital screening and treatment plan (electronic access outside of clinic room, multiple authorship and autosave functionality). These digital platforms reduced time and administration associated with use and increased access in and out of the clinic room. Digital systems also required clinicians to use (new) technological systems (Redcap, SharePoint). Additional resources were required to support knowledge assessment use and reduce time impact on clinicians, including creation of “red flag” scores and clinical follow up protocols, as well as feedback and education resources.

Non- CFIR Domains

Existing processes

(−)

Inconsistencies were identified within underlying clinic systems. Midway surveys identified that annual review processes were poorly understood by the clinical team. Therefore, pairing the local adherence protocol components with annual review reduced the frequency of use as rate of appointment booking for annual review was lower than anticipated. Inconsistencies were also identified in pre-clinic meeting processes and team communication prior to clinic. Therefore, the CF nurse was unable to inform parents of clinicians planning on seeing them at the clinic via the Clinic Communication Tool.