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Table 1 Description of sub-themes with examples

From: Implementation of clinical practice changes in the PICU: a qualitative study using and refining the iPARIHS framework

iPARIHS construct (s) iPARIHS sub-construct (s) Theme Sub-theme Description Example
Recipients
Context
Collaboration and teamwork
Local level:
Mechanisms for embedding change
PICU as a high-risk environment for clinical practice change (section 3.1) Complexity with team-based care Care is provided by multi-professional teams, each with different knowledge and expertise. Change required seeking out input, ensuring buy-in, or providing information to all teams, adding complexity “whenever you want to actually effect any kind of significant change, there’s a lot of people who have to get on board. And of course, as soon as you add more cooks in the kitchen things seem to slow down” (Site 1 CVICU, Attending 1).
Recipients
Context
Motivation
Local level: Culture
High-stakes limit receptivity to change PICU care and decision-making is high-risk, with potential for significant morbidity or mortality. Providers described a desire to avoid negative outcomes at all costs. “Our culture is that people like to use the same protocols because they’re proven, and not try to change…especially when it comes to babies’ health” (Site 2 CVICU, surgical subspecialist 34).
Recipients
Context
Values and beliefs; Motivation
Local level: Culture
Variable readiness for change Continuous changes in patient status and need for alterations in care plans make some providers ready to change, and some resistant to it. “People who work in ICU tend to be kind of constantly ready for a change in patient condition, they are also kind of hard wired or prepared for changes in other ways” (Site 3 PICU, NP 23)
“The unit is a …very intense and chaotic place. I think we crave stability and some of the stability is centered around easy decision making.” (Site 2 Combined PICU/CVICU, Attending 44)
Recipients
Context
Time, resources, support
Local level: Culture
Limited bandwidth Units often functioned at limits of capacity; providers felt overworked, reported units were understaffed. Staff and leadership turnover and temporary staff (i.e. traveling nurses, resident trainees) posed challenges to consistent use of new practice changes. “Inertia from being overworked is a barrier [to change]. People have really high clinical loads, so they don’t want to make a change. If it's not already part of your habit…gets pushed down the priorities” (Site 3 PICU, Fellow 22)
Context Local level: Culture Emotional toll of the PICU environment Emotional, physical and mental exhaustion noted due to unpredictable and difficult cases. Emotions influenced efforts to change practice. “Most kids do not have any of the procedures or outcomes that our patients do. I think that definitely flavors how people react to things... I think the stakes are higher in many ways for many of the things that we do, or at least it feels that way.” (Site 1 Combined PICU/CVICU, Attending 9).
Innovation Underlying knowledge sources Individual Determinants (section 3.4) Evidence for change Strong scientific evidence for change was a powerful stimulus to convince providers to change, particularly for physicians and NPs. “For providers – is it clinically relevant, does it provide a benefit? How much? We need to see research. We need to see data that shows that this is going to be worth the effort.” (Site 3 PICU, NP 24)
Innovation
Recipients
Relative advantage
Values and beliefs; Motivation
Rationale for change Rationale: Understanding the rationale for a change, goals, and potential benefits of a change were vitally important for all providers. “Sometimes people don’t fully understand the reason for trying to make a change… Either that it’s not relayed or explained in the right manner…if there was a better understanding they'd be more likely to be on board with it.” (Site 1 Combined PICU/CVICU, Attending 11)
Recipients Values and beliefs; Motivation Provider level factors: provider experience Apprehension around change: Providers noted being apprehensive about change, preferring the “old way to do things” “The hardest thing [about change] is people are just so used to doing it a certain way. It makes people nervous to change the way that they’ve always done things. It may take you out of your comfort zone, and people don’t like that.” (Site 4 PICU, NP 35)
Recipients Motivation; skills and knowledge Duration of Experience: More senior providers were often identified as being less receptive to change than less senior providers, however these providers also influenced practice and could facilitate acceptance of change. “The people who have been here for the longest, are the least likely to embrace change…The early adopters are the younger people. Especially the people who come from other places and who have seen it done differently.” (Site 1 CVICU, Attending, 2)
Recipients Values and beliefs; Motivation Provider level factors: beliefs Perceived need: Change was perceived as “needed” if 1) the existing process was frustrating, 2) the change prevented a bad outcome, or 3) it aligned with the provider’s priorities, hospital values, or practices at other centers (benchmarking). “I think [the change was easy because] everyone was a little bit frustrated with the lack of process, or protocol previously” (Site 1 PICU, Attending 6)
Recipients Values and beliefs; Motivation; Skills and knowledge Potential for negative outcome: Providers worried changes might have a negative impact on outcomes and new practices may be less safe in inexperienced hands. Significant shifts in practice were more difficult to accept. “It’s not just that we’re stuck in our ways. We want to do things that we know we’re good at and that are effective. Even if something [new] might be slightly more safe, is it more safe in my hands? I'm not sure.” (Site 1 PICU Attending 5)
Recipients Values and beliefs Compromised autonomy: Some providers felt creation of standard practices might compromise their autonomy. “Some people feel like they’re getting their freedom taken away…they aren’t going to have that creative freedom to choose how they want to manage a patient... when they feel like their overall authority is being taken away, it’s hard for some people” (Site 4 PICU, NP 35)
Recipients Values and beliefs; Motivation Provider level factors:
Perceived benefit/effort
Cost vs. benefit of change: Many changes require additional time or adding a task; the benefit of the change must exceed the “cost” of changing, otherwise it is less likely to be accepted or performed consistently. “There’s probably some balance of how important is [the change]? How easy is it? If something’s really important, even if it’s really difficult to do, people will do it. If something’s only moderately important then you probably need a low amount of resistance to do it.” (Site 2 CVICU, Fellow 29)
Recipients
Context
Time, resources, support
Local level: Culture
Competing interests and time Changes that were unrealistic due to other demands/tasks were unlikely to be supported or carried out. “It’s hard to keep adding all of these changes. We already do so much during a 12-h period. To add something else is just, “Why are we doing “one more thing”.” (Site 1 Combined PICU/CVICU, Nurse 13)