Mechanisms explain how implementation strategies work. Implementation research requires careful operationalisation and empirical study of the causal pathway(s) by which strategies effect change, and factors that may amplify or weaken their effects. Understanding mechanisms is critically important to replicate findings, learn from negative studies or adapt an implementation strategy developed in one setting to another. Without understanding implementation mechanisms, it is difficult to design strategies to produce expected effects across contexts, which may have disproportionate effects on settings in which priority populations receive care. This manuscript outlines the protocol for an Agency for Healthcare Research and Quality-funded initiative to: (1) establish priorities for an agenda to guide research on implementation mechanisms in health and public health, and (2) disseminate the agenda to research, policy and practice audiences.
A network of scientific experts will convene in ‘Deep Dive’ meetings across 3 years. A research agenda will be generated through analysis and synthesis of information from six sources: (1) systematic reviews, (2) network members’ approaches to studying mechanisms, (3) new proposals presented in implementation proposal feedback sessions, (4) working group sessions conducted in a leading implementation research training institute, (5) breakout sessions at the Society for Implementation Research Collaboration’s (SIRC) 2019 conference and (6) SIRC conference abstracts. Two members will extract mechanism-relevant text segments from each data source and a third member will generate statements as an input for concept mapping. Concept mapping will generate unique clusters of challenges, and the network will engage in a nominal group process to identify priorities for the research agenda.
This initiative will yield an actionable research agenda to guide research to identify and test mechanisms of change for implementation strategies. The agenda will be disseminated via multiple channels to solicit feedback and promote rigorous research on implementation mechanisms.
Vietnam is an endemic area for hepatitis B virus and hepatitis C virus infection (HBV-HCV), yet its largest city, Ho Chi Minh City (HCMC), has no comprehensive policy to educate, screen, treat and protect healthcare workers (HCWs) from viral hepatitis. We conducted a mixed-methods study to document HBV-HCV infection rates, risk factors, local barriers and opportunities for providing education, screening and medical care for HCWs.
This mixed-methods study involved an HBV and HCV serological evaluation, knowledge, attitude and practice survey about viral hepatitis and many in-depth interviews. Descriptive statistics and thematic content analysis using inductive and deductive approaches were used.
HCWs at risk of viral hepatitis exposure at three hospitals in HCMC.
Of the 210 invited HCWs, 203 were enrolled. Of the 203 HCWs enrolled, 20 were hepatitis B surface antigen-positive, 1 was anti-hepatitis C antibody (anti-HCV Ab)-positive, 57 were anti-hepatitis B core Ab-positive and 152 had adequate anti-hepatitis B surface Ab (anti-HBs Ab) titre (≥10IU/mL). Only 50% of the infected HCWs reported always using gloves during a clinical activity involving handling of blood or bodily fluid. Approximately 50% of HCWs were still not vaccinated against HBV following 1 year of employment. In-depth interviews revealed two major concerns for most interviewees: the need for financial support for HBV-HCV screening and treatment in HCWs and the need for specific HBV-HCV guidelines to be independently developed.
The high HBV infection rate in HCWs coupled with inadequate preventive occupational practices among the population in HCMC highlight the urgent needs to establish formal policy and rigorous education, screening, vaccination and treatment programmes to protect HCWs from HBV acquisition or to manage those living with chronic HBV in Vietnam.
Whilst theoretical grounding is considered important for sound research methodology, consensus on the application of theory in qualitative research remains elusive. Novice researchers may experience challenges in applying theory in qualitative research and these may contribute to the under-use, over-reliance or inappropriate application of theory. Practical guidance on how theory can inform and guide the conduct of qualitative research is needed.
The purpose of this paper was to propose a framework for the application of theory in qualitative research and provide an exemplar.
The Theoretical Application Framework for Qualitative Studies (TAF-QS) was developed from the synthesis of existing literature and the authors' own experience of the application of theory.
The TAF-QS encourages researchers to articulate which theoretical framework or conceptional framework they are drawing on and how this will be applied by reflecting on the purpose and the context of the study.
The TAF-QS provides support for researchers to explore how theory can be applied and how to achieve this in qualitative research.
The use of theory in qualitative research.
Apnoea affects 85% of premature infants under 34 weeks of age and would be an important risk factor for subsequent neuropsychological disorders. Currently, premature children with life-threatening apnoeas receive stimulants such as methylxanthines (mainly, caffeine) or doxapram (an analeptic unlicensed in children under 15). However, these products have undesirable effects (hyperarousal, irritability, sleep disorders, tachycardia) and are not always effective because apnoea does persist in some premature newborns. Previous studies have indicated that odorant stimulation, a non-invasive intervention, may stimulate the respiratory rhythm. The objective of the present protocol is to reduce the occurrence of apnoeic episodes in premature newborns by controlled odorant stimulation added to current pharmacological treatments.
The project is a randomised open-label Latin-square trial with independent evaluation of the main endpoint. It will include 60 preterm neonates from two university hospital neonatal intensive care units over 2 years (2021–2023). Each newborn will receive no (S0), sham (S1) or real olfactory stimulation (S2) in random order. During S2, three distinct odorants (mint, grapefruit and vanilla) will be delivered successively, in puffs, over 24 hours. Mint and grapefruit odours stimulate the main and the trigeminal olfactory pathways, whereas vanilla odour stimulates only the main olfactory pathway. A statistical analysis will compare the incidence of apnoeic episodes during S1 versus S2 using a mixed effects Poisson model.
Ethical approval was obtained from the Comité de Protection des Personnes Île-de-France XI (# 2017-AO13-50-53). The results will be disseminated through various scientific meetings, specialised peer-reviewed journals and, whenever possible, posted on appropriate public websites.
To identify the availability, prices and affordability of essential medicines for children (cEMs) in Hanam province, Vietnam.
One city and five districts of Hanam province.
66 public health facilities and 66 private drugstores.
The standardised methodology of the WHO and Health Action International was used to investigate 30 paediatric essential medicines. For each medicine, data were collected for two products: the lowest-priced medicine (LPM) and the highest-priced medicine (HPM). The availability of medicine was computed as the percentage of facilities in which this medicine was found on the day of data collection. Median prices of individual medicines were reported in local currency. Affordability was calculated as the number of days’ wages required for the lowest-paid unskilled government worker to purchase standard treatments for common diseases. Data were analysed using R software V.4.1.0.
The mean availability of LPMs in the private sector (33.2%, SD=38.0%) was higher than that in the public sector (24.9%, SD=39.4%) (p
The low availability was the main reason hindering access to cEMs in Hanam, especially in the countryside. A national study on cEMs should be conducted, and some practical policies should be promulgated to enhance access to cEMs.
Societal demographic shifts are occurring globally. Within Quebec, Canada, the percentage of adults over 65 (older adults) is predicted to increase from 19.3% to >25.9% by the year 2036. Older adults (OAs) experience hospitalizations more frequently than persons aged 15–64 years old, and hospitalizations for OAs can be detrimental due to naturally occurring physiological changes. To address the needs of this population, the Quebec government mandated that all acute care hospitals implement OA-friendly care standards called AAPA (“l’Approche Adaptée à la Personne Âgée”).
To describe an approach for identifying barriers and facilitators (BFs) to AAPA implementation at the McGill University Health Centre, an academic healthcare centre in Montreal that provides tertiary and quaternary care.
Our approach included an organizational quality improvement (QI) model based on the Institute for Healthcare Improvement QI approach and the use of the Theoretical Domains Framework (TDF) to guide the assessment of BFs to AAPA implementation. To identify the BFs of AAPA implementation, themes were generated from the raw data.
In total, 32 barriers and 88 facilitators were identified. Each BF was linked to one or more corresponding domain from the TDF. Seven of the most frequently occurring domains were: (1) knowledge, (2) beliefs about consequences, (3) social/professional role and identity, (4) social influences, (5) environmental context and resources, (6) intentions, and (7) goals.
A theory-informed approach, such as the TDF, can be used to facilitate the implementation of evidence-based guidelines.
by Ngo Ngoc Quang Minh, Pham Van Toi, Le Minh Qui, Le Binh Bao Tinh, Nguyen Thi Ngoc, Le Thi Ngoc Kim, Nguyen Hanh Uyen, Vu Thi Ty Hang, Nguyen Thi Thuy Chinh B’Krong, Nguyen Thi Tham, Thai Dang Khoa, Huynh Duy Khuong, Pham Quynh Vi, Nguyen Ngoc Hong Phuc, Le Thi Minh Vien, Thomas Pouplin, Doan Van Khanh, Pham Nguyen Phuong, Phung Khanh Lam, Heiman F. L. Wertheim, James I. Campbell, Stephen Baker, Christopher M. Parry, Juliet E. Bryant, Constance Schultsz, Nguyen Thanh Hung, Menno D. de Jong, H. Rogier van DoornBackground and objectives
Treatment guidelines do not recommend antibiotic use for acute respiratory infections (ARI), except for streptococcal pharyngitis/tonsillitis and pneumonia. However, antibiotics are prescribed frequently for children with ARI, often in absence of evidence for bacterial infection. The objectives of this study were 1) to assess the appropriateness of antibiotic prescriptions for mild ARI in paediatric outpatients in relation to available guidelines and detected pathogens, 2) to assess antibiotic use on presentation using questionnaires and detection in urine 3) to assess the carriage rates and proportions of resistant intestinal Enterobacteriaceae before, during and after consultation.Materials and methods
Patients were prospectively enrolled in Children’s Hospital 1, Ho Chi Minh City, Vietnam and diagnoses, prescribed therapy and outcome were recorded on first visit and on follow-up after 7 days. Respiratory bacterial and viral pathogens were detected using molecular assays. Antibiotic use before presentation was assessed using questionnaires and urine HPLC. The impact of antibiotic usage on intestinal Enterobacteriaceae was assessed with semi-quantitative culture on agar with and without antibiotics on presentation and after 7 and 28 days.Results
A total of 563 patients were enrolled between February 2009 and February 2010. Antibiotics were prescribed for all except 2 of 563 patients. The majority were 2nd and 3rd generation oral cephalosporins and amoxicillin with or without clavulanic acid. Respiratory viruses were detected in respiratory specimens of 72.5% of patients. Antibiotic use was considered inappropriate in 90.1% and 67.5%, based on guidelines and detected pathogens, respectively. On presentation parents reported antibiotic use for 22% of patients, 41% of parents did not know and 37% denied antibiotic use. Among these three groups, six commonly used antibiotics were detected with HPLC in patients’ urine in 49%, 40% and 14%, respectively. Temporary selection of 3rd generation cephalosporin resistant intestinal Enterobacteriaceae during antibiotic use was observed, with co-selection of resistance to aminoglycosides and fluoroquinolones.Conclusions
We report overuse and overprescription of antibiotics for uncomplicated ARI with selection of resistant intestinal Enterobacteriaceae, posing a risk for community transmission and persistence in a setting of a highly granular healthcare system and unrestricted access to antibiotics through private pharmacies.Registration
This study was registered at the International Standard Randomised Controlled Trials Number registry under number ISRCTN32862422: http://www.isrctn.com/ISRCTN32862422
To (a) characterise and determine proportions of referred and enrolled children and (b) explore public health nurses’ (PHNs) experiences, perspectives and recommendations regarding a new nurse‐led referral pathway for paediatric weight management.
Children with obesity and their families in Canada access specialised services for obesity management through physician referral. Since this requirement can prevent timely access to health services, we established and tested a referral pathway whereby PHNs directly refer children to specialised care for obesity management.
Nested mixed‐methods study reported using GRAMMS.
Our research study included children (2–17 years of age; body mass index ≥85th percentile) referred by a PHN to the Pediatric Centre for Weight and Health (PCWH; Stollery Children's Hospital, Edmonton, Alberta, Canada) from April 2017–September 2018. We summarised referral and enrolment data using descriptive statistics and conducted one‐on‐one, semi‐structured telephone interviews with PHNs; interviews were audio‐recorded, transcribed verbatim, managed using NVivo 12 and analysed by two independent reviewers using content analysis.
Our sample included 79 referred children (4.4 ± 1.8 years old; 3.4 ± 1.3 BMI z‐score; 52.7% male), of which 47 (59.5%) enrolled in care. PHNs’ (n = 11) experiences, perspectives and recommendations regarding the new referral pathway were grouped into four categories: (a) practicality of the referral pathway (e.g., simple and straightforward), (b) utility of the referral pathway (e.g., economic and timesaving), (c) uptake of the referral pathway (e.g., physician's influence) and (d) recommendations to improve the referral pathway (e.g., having electronic access to the referral form).
A PHN‐specific referral pathway led most children and families to enrol in paediatric weight management and overall was perceived as acceptable and appropriate among PHNs.
Our results highlight the valuable role that PHNs can play in directly referring children to specialised services for weight management. This pathway has the potential to reduce wait times and enhance treatment enrolment.
Cryopreserved human skin allografts (CHSAs) are used for the coverage of major burns when donor sites for autografts are insufficiently available and have clinically shown beneficial effects on chronic non‐healing wounds. However, the biologic mechanisms behind the regenerative properties of CHSA remain elusive. Furthermore, the impact of cryopreservation on the immunogenicity of CHSA has not been thoroughly investigated and raised concerns with regard to their clinical application. To investigate the importance and fate of living cells, we compared cryopreserved CHSA with human acellular dermal matrix (ADM) grafts in which living cells had been removed by chemical processing. Both grafts were subcutaneously implanted into C57BL/6 mice and explanted after 1, 3, 7, and 28 days (n = 5 per group). A sham surgery where no graft was implanted served as a control. Transmission electron microscopy (TEM) and flow cytometry were used to characterise the ultrastructure and cells within CHSA before implantation. Immunofluorescent staining of tissue sections was used to determine the immune reaction against the implanted grafts, the rate of apoptotic cells, and vascularisation as well as collagen content of the overlaying murine dermis. Digital quantification of collagen fibre alignment on tissue sections was used to quantify the degree of fibrosis within the murine dermis. A substantial population of live human cells with intact organelles was identified in CHSA prior to implantation. Subcutaneous pockets with implanted xenografts or ADMs healed without clinically apparent rejection and with a similar cellular immune response. CHSA implantation largely preserved the cellularity of the overlying murine dermis, whereas ADM was associated with a significantly higher rate of cellular apoptosis, identified by cleaved caspase‐3 staining, and a stronger dendritic cell infiltration of the murine dermis. CHSA was found to induce a local angiogenic response, leading to significantly more vascularisation of the murine dermis compared with ADM and sham surgery on day 7. By day 28, aggregate collagen‐1 content within the murine dermis was greater following CHSA implantation compared with ADM. Collagen fibre alignment of the murine dermis, correlating with the degree of fibrosis, was significantly greater in the ADM group, whereas CHSA maintained the characteristic basket weave pattern of the native murine dermis. Our data indicate that CHSAs promote angiogenesis and collagen‐1 production without eliciting a significant fibrotic response in a xenograft model. These findings may provide insight into the beneficial effects clinically observed after treatment of chronic wounds and burns with CHSA.
To explore nursing students’ subjective experience of emotions during first‐year clinical placements, strategies used to manage their emotions and socialisation to emotion management.
Emotion regulation is a key source of stress for early career and student nurses. Clinical placement experiences can elicit strong emotions in nursing students; however, they may be unprepared for the challenge of regulating their emotions in real‐world practice. How nursing students learn to manage their emotions in the clinical setting, whether they receive support for this, and how they are socialised to manage their emotions during placements are not well known.
An exploratory qualitative study.
Semi‐structured interviews (n = 19) were conducted with first‐year nursing students, exploring their experiences of emotion management during clinical placement. Interview transcripts were analysed using conventional qualitative content analysis. Reporting adheres to the COREQ Checklist.
Interactions with patients and staff often elicited negative feelings. Structured guidance for emotion management by supervising staff was scarce. Students used informal self‐reflection and interpretation to guide emotion management.
In the absence of strategic socialisation and formal support for effective emotion management, students used emotional labour strategies that can negatively impact on well‐being. A focus on adequately preparing nursing students for emotion work is a necessary component of classroom and clinical learning environments. Structured debriefing during clinical placements may provide a relevant context to discuss emotions arising during clinical work and to learn emotion management strategies.
Emotional competence, a fundamental ability for registered nurses and students, supports personal health maintenance and strengthens professional practice. Students are exposed to clinical environments and interpersonal encounters that evoke strong emotions. They need situated learning strategies and formal support to develop knowledge and strengthen capability for emotion management, as this is essential for promoting professional development and patient care.
by Neema Jamshidi, Jason Chang, Kyle Mock, Brian Nguyen, Christine Dauphine, Michael D Kuo
To evaluate the enablers, barriers and impact that communities of practice have on novice nurses and students learning to become registered nurses.
Communities of practice have formed the basis for conceptualising the process of learning that occurs among groups of people within a place of work—a mainstay of healthcare practice. There is a dearth of literature that focuses specifically on the outcomes from student and novice engagement with existing communities of practice.
Systematic review and Meta‐synthesis.
MEDLINE, PubMed, EMBASE, CINAHL, ProQuest, Scopus and PsycINFO databases were accessed between 1997–2019. The screening and selection of studies were based on eligibility criteria and methodological quality assessment using the Critical Appraisal Skills Programme tool for qualitative research. Meta‐synthesis was grounded in the original experiences and collectively synthesised into meaningful themes. The review follows the PRISMA reporting guidelines and PRISMA checklist.
The findings highlight three major themes and included enablers for successful communities of practice, barriers to successful communities of practice, and success in action as described by students and novice nurses.
We suggest successful communities of practice occur when safe and supported spaces ensure students and novices feel comfortable to experiment with their learning, and we emphasise the benefits of having more novice nurses situated within close proximity and under the direct influence of the established practices of more experienced or core group of peers.
Communities of practice that function successfully create an environment that prioritises the embedding of novices into the broader group. In so doing, students and novice nurses feel supported, welcomed, empowered, and able to make the transition from student to colleague and novice nurse to more experienced nurse. It allows them to experiment with ever new ways of fulfilling the role, while aiding better clinical outcomes.
Postsurgical patients experiencing opioid‐related adverse drug events have 55% longer hospital stays, 47% higher costs associated with their care, 36% increased risk of 30‐day readmission, and 3.4 times higher risk of inpatient mortality compared to those with no opioid‐related adverse drug events. Most of the adverse events are preventable.
This study explored three types of electronic monitoring devices (pulse oximetry, capnography, and minute ventilation [MV]) to determine which were more effective at identifying the patient experiencing respiratory compromise and, further, to determine whether algorithms could be developed from the electronic monitoring data to aid in earlier detection of respiratory depression.
A study was performed in the postanesthesia care unit (PACU) in an inner city. Sixty patients were recruited in the preoperative admissions department on the day of their surgery. Forty‐eight of the 60 patients wore three types of electronic monitoring devices while they were recovering from back, neck, hip, or knee surgery. Machine learning models were used for the analysis.
Twenty‐four of the 48 patients exhibited sustained signs of opioid‐induced respiratory depression (OIRD). Although the SpO2 values did not change, end‐tidal CO2 levels increased, and MV decreased, representing hypoventilation. A machine learning model was able to predict an OIRD event 10 min before the actual event occurred with 80% accuracy.
Electronic monitoring devices are currently used as a tool to assess respiratory status using thresholds to distinguish when respiratory depression has occurred. This study introduces a potential paradigm shift from a reactive approach to a proactive approach that would identify a patient at high risk for OIRD. Capnography and MV were found to be effective tools in detecting respiratory compromise in the PACU.
The Hawthorne Effect (HE) is considered a methodological artefact in research, although its definition and influence on research outcomes lack consensus. This review explored how this term has been mentioned and discussed in the area of wound research. A scoping review was conducted on ProQuest Central, Scopus, EbscoHost, and online databases of indexed wound journals using the methodological framework by Arksey and Malley. A review protocol was applied to detail key terms, truncation and Boolean operators, and inclusion and exclusion criteria. Search findings were reported using PRISMA guidelines. A total of 38 articles reporting primary evidence were identified. Three themes emerged from the review: wound researchers' awareness of HE, the acknowledgement of the existence or otherwise of HE, and the mentioning of HE in passing. These results reflect a lack of attention to and understanding and awareness of the HE in the area of wound research. It is suggested that the HE receives more attention as a methodological concern, and its potential influence is considered and mitigated when planning future studies. Recommendations are provided to minimise the impact of the HE on the rigour of the research and confidence afforded to research findings.