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The South African National Department of Health developed a quality improvement (QI) programme to reduce maternal and neonatal mortality and still births. The programme was implemented between 2018 and 2022 in 21 purposively selected public health facilities. We conducted a process evaluation to describe the characteristics and skills of the QI team leaders of well-performing teams. The evaluation was conducted in 15 of the 21 facilities. Facilities were purposively selected and comprised semi-structured interviews with leaders at three time points; reviewing of QI documentation; and 37 intermittently conducted semi-structured interviews with the QI advisors, being QI technical experts who supported the teams. These interviews focused on participants’ experiences and perceptions of how the teams performed, and performance barriers and enablers. Thematic data analysis was conducted using Atlas.ti. Variation in team performance was associated with leaders’ attributes and skills. However, the COVID-19 pandemic also affected team functioning. Well-performing teams had leaders who effectively navigated COVID-19 and other challenges, who embraced QI and had sound QI skills. These leaders cultivated trust by taking responsibility for failures, correcting members’ mistakes in encouraging ways, and setting high standards of care. Moreover, they promoted programme ownership among members by delegating tasks. Given the critical role leaders play in team performance and thus in the outcomes of QI programmes, efforts should focus on leader selection, training, and support.

Background Effective implementation of evidence-based practices (EBPs) remains a significant challenge. Numerous existing models and frameworks identify key factors and processes to facilitate implementation. However, there is a need to better understand how individual models and frameworks are applied in research projects, how they can support the implementation process, and how they might advance implementation science. This systematic review examines and describes the research application of a widely used implementation framework, the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Methods A systematic literature review was performed to identify and evaluate the use of the EPIS framework in implementation efforts. Citation searches in PubMed, Scopus, PsycINFO, ERIC, Web of Science, Social Sciences Index, and Google Scholar databases were undertaken. Data extraction included the objective, language, country, setting, sector, EBP, study design, methodology, level(s) of data collection, unit(s) of analysis, use of EPIS (i.e., purpose), implementation factors and processes, EPIS stages, implementation strategy, implementation outcomes, and overall depth of EPIS use (rated on a 1–5 scale). Results In total, 762 full-text articles were screened by four reviewers, resulting in inclusion of 67 articles, representing 49 unique research projects. All included projects were conducted in public sector settings. The majority of projects (73%) investigated the implementation of a specific EBP. The majority of projects (90%) examined inner context factors, 57% examined outer context factors, 37% examined innovation factors, and 31% bridging factors (i.e., factors that cross or link the outer system and inner organizational context). On average, projects measured EPIS factors across two of the EPIS phases ( M  = 2.02), with the most frequent phase being Implementation (73%). On average, the overall depth of EPIS inclusion was moderate (2.8 out of 5). Conclusion This systematic review enumerated multiple settings and ways the EPIS framework has been applied in implementation research projects, and summarized promising characteristics and strengths of the framework, illustrated with examples. Recommendations for future use include more precise operationalization of factors, increased depth and breadth of application, development of aligned measures, and broadening of user networks. Additional resources supporting the operationalization of EPIS are available.

PRISM is useful to identify contextual factors that influence implementation, modification, uptake, and evaluation of health services programs.AbstractThere is consensus in dissemination and implementation (D&I) science that addressing contextual factors is critically important for understanding translation of health care delivery interventions but little agreement on which contextual factors are key determinants of implementation outcomes. We describe the application of the Practical Robust Implementation and Sustainability Model (PRISM), which expands the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to identify contextual factors across four diverse programs. Multiple qualitative methods were used to collect multilevel, multistakeholder perspectives from the adopting organizations and staff. We identified measures for evaluating context through the various domains of PRISM to guide health services research across the phases of program implementation. The PRISM domains of Recipients, Implementation and Sustainability Infrastructure, and External Environment identified important multilevel contextual factors, including variability in operational processes and available resources. These domains helped to facilitate planning and implementation phases of the four interventions and guide purposeful adaptations. We found assessments of PRISM domains useful to systematically assess multilevel contextual factors across various content areas as well as phases of program implementation. Additionally, these contextual factors were found to be relevant to RE-AIM outcomes. Lessons learned can be applied to future research as there is a need to investigate the measurement properties of PRISM and continue to test which contextual factors are most important to successful implementation and for which outcomes.

Background Healthcare organisations are complex social entities, comprising of multiple stakeholders with differing priorities, roles, and expectations about how care should be delivered. To reach agreement among these diverse interest groups and achieve safe, cost-effective patient care, healthcare staff must navigate the micropolitical context of the health service. Micropolitics in this study refers to the use of power, authority, and influence to affect team goals, vision, and decision-making processes. Although these concepts are influential when cultivating change, there is a dearth of literature examining the mechanisms through which micropolitics influences implementation processes among teams. This paper addresses this gap by exploring the role of power, authority, and influence when implementing a collective leadership intervention in two multidisciplinary healthcare teams. Methods The multiple case study design adopted employed a triangulation of qualitative research methods. Over thirty hours of observations (Case A = 16, Case B = 15) and twenty-five interviews (Case A = 13, Case B = 12) were completed. An in-depth thematic analysis of the data using an inductive coding approach was completed to understand the mechanisms through which contextual factors influenced implementation success. A context coding framework was also employed throughout implementation to succinctly collate the data into a visual display and to provide a high-level overview of implementation effect (i.e. the positive, neutral, or negative impact of contextual determinants on implementation). Results The findings emphasised that implementing change in healthcare teams is an inherently political process influenced by prevailing power structures. Two key themes were generated which revealed the dynamic role of these concepts throughout implementation: 1) Exerting hierarchical influence for implementation; and 2) Traditional power structures constraining implementation. Gaining support across multiple levels of leadership was influential to implementation success as the influence exercised by these individuals persuaded follower engagement. However, the historical dynamics of each team determined how this influence was exerted and perceived, which negatively impacted some participants’ experiences of the implementation process. Conclusion To date, micropolitics has received scant attention in implementation science literature. This study introduces the micropolitical concepts of power, authority and influence as essential contextual determinants and outlines the mechanisms through which these concepts influence implementation processes.

Background For successful implementation of an innovation within a complex adaptive system, we need to understand the ways that implementation processes and their contexts shape each other. To do this, we need to explore the work people do to make sense of an innovation and integrate it into their workflow and the contextual elements that impact implementation. Combining Normalization Process Theory (NPT) with the Consolidated Framework for Implementation Research (CFIR) offers an approach to achieve this. NPT is an implementation process theory that explains how changes in the way people think about and use an innovation occurs, while CFIR is a framework that categorizes and describes contextual determinants across five domains that influence implementation. We demonstrate through a case example from our prior research how we integrated NPT and CFIR to inform the development of the interview guide, coding manual, and analysis of the findings. Methods In collaboration with our stakeholders, we selected NPT and CFIR to study the implementation process and co-developed an interview guide to elicit responses that would illuminate concepts from both. We conducted, audio-recorded, and transcribed 28 interviews with various professionals involved with the implementation. Based on independent coding of select transcripts and team discussion comparing, clarifying, and crystallizing codes, we developed a coding manual integrating CFIR and NPT constructs. We applied the integrated codes to all interview transcripts. Results Our findings highlight how integrating CFIR domains with NPT mechanisms adds explanatory strength to the analysis of implementation processes, with particular implications for practical strategies to facilitate implementation. Multiple coding across both theoretical frames captured the entanglement of process and context. Integrating NPT and CFIR enriched understandings of how interactions between implementation processes and contextual determinants shaped each other during implementation. Conclusion The integration of NPT and CFIR provides guidance to identify and explore complex entangled interactions between agents, processes, and contextual conditions within and beyond organizations to embed innovations into routine practices. Nuanced understandings gained through this approach moves understandings beyond descriptions of determinants to explain how change occurs or not during implementation. Mechanism-based explanations illuminate concrete practical strategies to support implementation.

Veterans and First Responders (VFR) are at risk of developing a range of mental health disorders because of cumulative exposure to critical incidents at work. Two Philanthropic organisations funded 15 organisations, which collectively implemented 23 highly heterogeneous and international early intervention mental ill-health and suicide prevention Projects. The aim was identify and collaborate with Projects with a multi-project evaluation. The evaluation examined multiple domains including intervention effectiveness but critically the implementation processes impacts for potential replication or scale up. This paper reports on the methods and evaluation results of implementation processes, impact analysis and sustainability. The evaluation involved ecosystems and complex systems approaches using novel methods and tools. There was multiple preparatory evaluation steps including developing indices for complexity and context. The Global Impact Analytics Framework (GIAF) toolkit was used to evaluate the implementation processes. Methodological tools included qualitative analysis, descriptive statistics, GIAF ladders/scales and checklists (qualitative and quantitative data). We provide the results on characteristics (organisational, Project and participants), GIAF process components (planning, pre-engagement, pre-readiness/readiness, dissemination/diffusion, usability/sustainability, adoption and uptake). All Project interventions were assessed as usable, adoptable and have capacity to be sustained, with financial resources. Uptake of the intervention was mostly high. Complex multi-project evaluation of highly heterogenous Projects implemented in the real world across different countries is possible and provides valuable information and learnings. The evaluation results establish benchmarks including Project pre-engagement with potential end-users, continuous, frequent collaboration between Project and evaluation teams, adequate contract duration for sufficient recruitment and intervention. •Whilst challenging, evaluation of multiple and highly complex, heterogenous Projects in different countries is possible but requires an ecosystem approach, mixed and novel methods rather than a traditional outcome focused evaluation approach.•In real world implementation research, evaluations require extensive and continuous collaborations with the Projects for data collection and knowledge sharing prior to analysis.•The extensive and complex evaluation affirms the need for multiple domains to be considered, measured and evaluated in any multi-project/study and international evaluation.•The GIAF provides a useful tool for measuring implementation processes and impacts of heterogenous projects.•Knowledge sharing throughout the evaluation produced critical evaluation results and valuable organisational learnings relevant to future evaluations.

Background Operating room (OR) crises are high-acuity events requiring rapid, coordinated management. Medical judgment and decision-making can be compromised in stressful situations, and clinicians may not experience a crisis for many years. A cognitive aid (e.g., checklist) for the most common types of crises in the OR may improve management during unexpected and rare events. While implementation strategies for innovations such as cognitive aids for routine use are becoming better understood, cognitive aids that are rarely used are not yet well understood. We examined organizational context and implementation process factors influencing the use of cognitive aids for OR crises. Methods We conducted a cross-sectional study using a Web-based survey of individuals who had downloaded OR cognitive aids from the websites of Ariadne Labs or Stanford University between January 2013 and January 2016. In this paper, we report on the experience of 368 respondents from US hospitals and ambulatory surgical centers. We analyzed the relationship of more successful implementation (measured as reported regular cognitive aid use during applicable clinical events) with organizational context and with participation in a multi-step implementation process. We used multivariable logistic regression to identify significant predictors of reported, regular OR cognitive aid use during OR crises. Results In the multivariable logistic regression, small facility size was associated with a fourfold increase in the odds of a facility reporting more successful implementation ( p  = 0.0092). Completing more implementation steps was also significantly associated with more successful implementation; each implementation step completed was associated with just over 50% higher odds of more successful implementation ( p  ≤ 0.0001). More successful implementation was associated with leadership support ( p  < 0.0001) and dedicated time to train staff ( p  = 0.0189). Less successful implementation was associated with resistance among clinical providers to using cognitive aids ( p  < 0.0001), absence of an implementation champion ( p  = 0.0126), and unsatisfactory content or design of the cognitive aid ( p  = 0.0112). Conclusions Successful implementation of cognitive aids in ORs was associated with a supportive organizational context and following a multi-step implementation process. Building strong organizational support and following a well-planned multi-step implementation process will likely increase the use of OR cognitive aids during intraoperative crises, which may improve patient outcomes.

Background Facilitation is a promising implementation intervention, which requires theory-informed evaluation. This paper presents an exemplar of a multi-country realist process evaluation that was embedded in the first international randomised controlled trial evaluating two types of facilitation for implementing urinary continence care recommendations. We aimed to uncover what worked (and did not work), for whom, how, why and in what circumstances during the process of implementing the facilitation interventions in practice. Methods This realist process evaluation included theory formulation, theory testing and refining. Data were collected in 24 care home sites across four European countries. Data were collected over four time points using multiple qualitative methods: observation (372 h), interviews with staff ( n  = 357), residents ( n  = 152), next of kin ( n  = 109) and other stakeholders ( n  = 128), supplemented by facilitator activity logs. A combined inductive and deductive data analysis process focused on realist theory refinement and testing. Results The content and approach of the two facilitation programmes prompted variable opportunities to align and realign support with the needs and expectations of facilitators and homes. This influenced their level of confidence in fulfilling the facilitator role and ability to deliver the intervention as planned. The success of intervention implementation was largely dependent on whether sites prioritised their involvement in both the study and the facilitation programme. In contexts where the study was prioritised (including release of resources) and where managers and staff support was sustained, this prompted collective engagement (as an attitude and action). Internal facilitators’ (IF) personal characteristics and abilities, including personal and formal authority, in combination with a supportive environment prompted by managers triggered the potential for learning over time. Learning over time resulted in a sense of confidence and personal growth, and enactment of the facilitation role, which resulted in practice changes. Conclusion The scale and multi-country nature of this study provided a novel context to conduct one of the few trial embedded realist-informed process evaluations. In addition to providing an explanatory account of implementation processes, a conceptual platform for future facilitation research is presented. Finally, a realist-informed process evaluation framework is outlined, which could inform future research of this nature. Trial registration Current controlled trials ISRCTN11598502 .

Nursing education research is complex and contextualized. The evaluation and impact of educational innovations on students, educators, and educational outcomes are influenced by the complexity of environments. Most interventional research in nursing is designed and implemented without considering the behavioral and contextual issues affecting educational innovations, uptake and change processes, and outcomes. Implementation science has emerged as a valuable methodology for designing and conducting interventional research that has the potential to translate evidence and innovations quickly into practice. This paper aims to explore the value of implementation science theories, models, and frameworks and hybrid designs for interventional nursing education research and illustrate how these can be used in nursing education research. A brief overview of implementation science, the various types of theories, models and frameworks and Hybrid designs are provided. Illustrative examples demonstrating the incorporation of these methodologies in interventional nursing education research are provided. A brief overview of implementation and its key concepts namely context, implementation strategies, fidelity, outcomes, adaptation, and sustainability is provided. Three types of hybrid designs are discussed with examples in nursing education research. The implications of implementation science for nursing education research are: a) Accelerating uptake of innovations to improve educational outcomes, b) targeting systematic change in individual and organizational behaviour and c) ensuring the sustainability of teaching and learning innovations. Incorporating implementation science in nursing education research can optimize the uptake of educational innovations in practice in a sustainable manner. Nurse educators should equip themselves with implementation science skills and develop competencies to enhance the delivery of effective and quality nursing education.

PurposeThe authors share a real-world case study of a multiple-year adoption process of robotic process automation (RPA) in procurement to add to the limited empirical research base on RPA in supply chain management. The Maersk case offers hard evidence of the value of RPA that can be used as a benchmark for decision-making in companies and as a basis for further research in key areas such as change management and behavioral aspects as well as return on investment on RPA and the need for RPA capability development.Design/methodology/approachTogether with the co-author from Maersk, the authors cover a multiple year RPA program in procurements, to capture lessons learned and develop research questions for the future. The authors consider 39 generic action principles for RPA adoption in a specific procurement context.FindingsThe authors find RPA for procurement to be an enabler of strategic progress and of advancing the concept of triple values (enterprise, customer and employee) in a supply chain setting. The authors offer RPA adoption scoping guidance and show how, with growth and maturity of the program, conditions such as predictability of volume become less relevant as a scoping criterium. The authors also find that RPA augments work rather than replace staff. Maersk utilizes staff time freed up by automation to focus employees on more strategic priorities. The authors consider 39 generic action principles for RPA adoption in a procurement-specific context and develop additional action principles based upon the Maersk case.Originality/valueThe authors study both a unique and rich case to complement limited empirical research on RPA in procurement and supply chain management and the limited research into RPA past early stage adoptions. The authors address Hofmann et al.'s (2019) questions about the change management involved in RPA and consider generic RPA action principles from literature in this specific procurement setting. The authors extend those action principles and develop a rich set of research opportunities.