We analyzed data from interviews (n = 27) representing three intervention sites: site A – 13 interviews; site B – 8 interviews; site C – 6 interviews. Professions/roles represented across intervention sites include: administrator – 6 interviews; physician/non-physician primary care provider – 9 interviews; nurse – 9 interviews; information technology staff – 3 interviews. Interviews averaged approximately 20 minutes. Qualitative results were summarized (Table 1) and organized according to the Weiner Organizational Theory of Implementation Effectiveness (Figure 1) [8, 9].
Of the 102 respondents to the ORC survey, 74 completed it (Table 2). It is unknown why the other 28 respondents initiated but did not complete the survey. Survey responders were a mix of representatives from the three facilities. The majority of responders were clinicians, those engaged in the delivery of patient care, with limited input from non-clinical roles. Of the respondents 27 (27%) were physicians, 59 (58%) were nurses, 10 (10%) were non-physician providers (NP/PA), 4 (4%), were administrators, and 1 (1%), was an IT professional. Patterns of missing data, both in terms of non-responders and survey items, were evaluated; related to profession, intervention site, and/or survey item, there was no discernible pattern of non-response (Table 2). Below, we describe organizational attributes that lead to organizational staff members to rate a medical center’s readiness to implement a nurse-delivered telephone self-management program and specific groups of factors that would be expected to impact this readiness: situation factors, change valence, task demands, and resource availability. Results are organized according to the Weiner Organizational Theory of Implementation Effectiveness (Figure 1) [8, 9].
Overall, intervention sites expressed readiness to implement the program as demonstrated by the positive results, defined as a facilitator toward implementation, from the interviews (Table 1) and survey items (Table 2). There were limited differences in readiness to implement by intervention site in the results. This included minor differences in reported resource availability. Differences in the perception of ORC did however exist between professions such that nursing was concerned with increased workload and dedicated staff time to conduct the intervention. Figure 2 presents a summary of the key findings.
Organizational readiness to change (ORC)
ORC refers to the extent to which organizational members are prepared as a group to make the changes in organizational policies and practices that are necessary to implement and support innovation use (change commitment) and their perceived ability to do so (change efficacy) [25]. Administration was committed to implementation as demonstrated by their devotion of the required 0.5 FTE. Information technology staff members were confident in their ability to implement the software due to their previous experience with similar research and that there was buy-in from administration.
Still, the commitment by individual nurses and nursing administration was difficult to gauge. There was reluctance by the nurse interventionists due to uncertainty of time commitment and fear of creep in the scope of the time needed for the nurse-delivered telephone calls. There was also a fear that due to the length of implementation time, buy-in was waning, and the devoted nursing time would be permanently shifted to other tasks they had taken up during the pre-implementation phase. One nurse administrator said:
I would just say, with something like this, when it’s a research project, when it first comes out and the leadership is told we’re going to try this, we’re going to implement this here and then now we’re almost a year later. The timeliness of ‘we have an idea, we have a project we’d like to implement’, if it could happen within a three-month timeframe, I think buy-in and support would happen a lot better.
With regard to change commitment and change efficacy, organizational members were favorable toward the task demands required of HTN-IMPROVE, resources were adequate in the immediate future for implementation, and situational factors supported the program. Existing situational factors (e.g., telehealth), helped support buy-in and the view that the intervention could be implemented successfully. This is supported by responses to the survey (Table 2). Nearly 70% reported that the core group of people leading the implementation wanted to put HTN-IMPROVE into practice ‘very much’. Similarly, 69% said that the clinicians expected to support the program were either ‘fairly’ or ‘very committed’ to implement the program. Regarding motivation of the clinicians using the program, nearly one-quarter reported that they were ‘very motivated’ to implement the program, and 36% indicated that that they were ‘fairly motivated’. Of respondents, 39% reported that their clinical work group ‘very’ much wanted to implement the program, and another 43% reported that they ‘somewhat’ wanted to implement the program. Overall, the positive factors associated with implementation outweighed the negative, and the organizations expressed readiness for change.
Change valence
Change valence refers to the value that organizational members attribute to a proposed change [9, 25]. Change valence was largely positive with stakeholders expressing many benefits for patients including increased access to care, the ability to telecommute, both of which add to and complement current care. Value in the new program was expressed in large part because HTN-IMPROVE is an evidence-based intervention that has demonstrated efficacy and cost-effectiveness [7] and would fit with the organizations’ missions, goals and values of improving patient care. Ninety-three percent of survey respondents agreed or strongly agreed that ‘self-management programs fit with our approach to patient care’ (Table 2). Clinicians and administrators also perceived that the telephone-based aspect of the intervention was of particular benefit to patients; it is convenient with no need for patients to commute and would allow the intervention sites to provide cost-effective additional care to patients. One clinician stated, ‘I think the qualitative evidence should be highly stressed. You know, how are the veteran’s feeling? How are the clinicians feeling? Is there a sense of … pride in taking part in really helping the veterans out in this way and equally, if not more important, are the veterans really happy that they’re being reached out to a little more frequently?’
From a professional role perspective, nurses often expressed that the nurse-delivered intervention allowed them to practice to a fuller extent of their license and training; nurses would feel ownership of their patients, independence in their job, and increased job satisfaction. For example, HTN-IMPROVE allowed the nurses to move beyond routine clinic work and be increasingly engaged in their patients’ care, education and self-management.
Informational assessment
Task demands
Task demands refer to knowledge about the tasks that need to be performed, resources that are needed, and the time and effort that are needed to implement the intervention [9, 25]. Due to the length of implementation in 2011 from initial information sessions in 2008, many participants had forgotten, in part, the specific tasks involved with the program. Once the interviewer either reminded or explained the intervention, participants were comfortable with the tasks needed for intervention implementation. Knowledge of the intervention also varied by role; for example, administrators and clinicians had a good understanding of the clinical tasks that would be required to conduct the intervention. However, the IT staff was less familiar with the clinical needs and predominately focused on the IT infrastructure and programming needs of the intervention.
Resource perceptions
Resource availability refers to the accessibility of financial, material or human assets that can be used to support initial and ongoing use [9, 25]. Overall, most participants stated that they would be able to use existing office space, equipment, and IT support to implement and sustain HTN-IMPROVE. This resonated in the survey responses (e.g., between 60% and 66% of respondents indicated that they generally had sufficient resources to implement the program; see Table 2). The availability and ability to use already existing infrastructure was a major positive element of the implementation. Because each institution has dedicated nursing time to devote to the project, staffing time for initial implementation is available. Thus, securing financial resources for human and material resources was less of a concern.
However, available staffing time/available individuals over the long term were a concern. Because the intervention sites had yet to implement the project, there was also concern by both the nurses and providers as to actual workload that would be added. Furthermore, due to the length of implementation time, nurses and administrators were concerned about losing the dedicated staff time to conduct the intervention. Prior to implementation, the nurse time was used for other tasks that many were afraid they would not be able to relinquish once HTN-IMPROVE went live. Administrators also noted that there were not additional financial resources available, such as a dedicated staff member for implementation.
Situational factors
Situational factors refer to the contextual factors that affect the confidence and commitment of organizational members to implement the intervention [9, 25]. Major situational factors that arose included the following: competing demands, competing clinical programs, timing of the change effort, available time, and technological factors. Interviewees, particularly clinicians, noted that the intervention may compete with patient care needs and the limited time available per patient during a visit. This was also supported in the survey responses. Twenty percent of respondents said they did not know whether HTN-IMPROVE would divert attention for other high-priority clinical activities (Table 2). Moreover, 40% agreed or strongly agreed that the program would divert attention from other high-priority clinical activities. It may also compete with existing programs such as existing telehealth programs and the patient-centered medical home, a care setting that facilitates a team-based approach to care where the patient, family, and a variety of clinicians work together to deliver patient-centered care. For example, the rollout of HTN-IMPROVE was concurrent with the patient-centered medical home program as site B and may have been seen as a competing demand. These barriers were matched with an overall perception that there may not be enough time to implement and conduct the intervention in an already busy clinic that requires coordination between multiple players. Nurses particularly were concerned that patients might over utilize the phone contact to address other health issues and concerns that, although important, would consume substantial time that had not been allotted to the nursing staff to address. There were also staffing concerns. Even though 0.5 FTE was devoted by each intervention to conduct the intervention, clinicians were unsure who would cover the additional workload when staff are out of the office (i.e., sick or on vacation).
Timing of the change effort also arose as a potential barrier. Due to implementation challenges, such as IRB approval among others, significant time had lapsed since the intervention was announced in 2008 to be implemented and the time when the interviews were conducted in 2011. Staff were concerned that buy-in and eagerness to try this new intervention were waning and that staffing time devoted would be drawn away to cover other needed clinical tasks that would become non-retractable. Of the survey respondents, 21% said they did not know whether the timing was good to implement HTN-IMPROVE, while approximately 64% either agreed or strongly agreed that the timing was good (Table 2).
Despite these barriers, there were many positive factors associated with the implementation. It was noted that this would be particularly useful for patients because participation in the HTN-IMPROVE program would not be required to commute to the intervention site. HTN-IMPROVE also has many of the same values as the patient medical home and thus will complement its efforts of a group approach to patient care management. Furthermore, the intervention will be supported by other telehealth-based programs that the staff is already familiar with and perceive as valuable. Further, research was noted to be part of the intervention sites’ culture and was a facilitator of buy-in for this intervention.
Due to the large information technology component of HTN-IMPROVE, technological and situational factors were both noted as facilitators and barriers towards implementation. As anticipated, IT staff were able to speak to many of the technicalities involved with this facet of implementation. The intervention was easily added to the existing technology infrastructure and workflow. However, there were particular issues such as security and access to patient data to the software program. For example, it was unclear how covering clinicians would have quick access to the software program when the primary clinician was out of the office (i.e., vacation or out sick). Clinicians also explicitly spoke to an anticipated clinical reminder overload that is already rampant in the existing electronic health record [26]. Interoperability challenges were also a concern by the IT staff. Because the intervention was not implemented on a national VA level, each intervention site was concerned with how they have to fit the software program to its local IT infrastructure. Lastly, from a national organizational-level, the IT department was being restructured, and there was uncertainty as to who would be responsible for different aspects of the implementation process and ongoing maintenance of the program. This created future uncertainty in regard to resource allocation of IT staff to the project but was important for the key stakeholders to be aware of and monitor. As indicated by one of IT staff, ‘But as OI&T [Office of Information and Technology] moves further away from VHA [Veterans Health Administration], the negotiations may take longer or some things actually happen faster and some things may happen slower. It’s just… it’s a new world and we’re not sure who’s going to make the priorities’.
Contextual factors
Contextual factors refer to the broader conditions that affect an organization’s readiness for change [8, 9]. Contextual factors were for the most part facilitators of readiness for change. The intervention sites involved in the implementation were accustomed to innovation and, in large part due to their affiliation with academic medical centers, noted that research is a part of the culture. Many of the staff, including administration, providers, nurses, and IT, had past experience with implementing experimental programs in the clinical setting. Furthermore, the staff had experience with implementing other hypertension-specific programs, including a hypertension clinic and nurse-led telehealth with hypertension elements. Lastly, telemedicine was already part of the VA culture, and staff overall expressed its perceived value. However, there were some contextual factors that had a negative influence. Though research is part of the culture, there was no noted designated research staff for the implementation of this program. Also, because of the IT nature of HTN-IMPROVE, there was concern that future support may not be available or would have to go through other channels due to the changing infrastructure of the larger VA organizations’ IT changes.