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Strategies to improve the implementation of infection control link nurse programmes in acute-care hospitals

  • M. Dekker
    Correspondence
    Corresponding author. Address: De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands. Tel.: +31 6 50087569.
    Affiliations
    Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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  • I.P. Jongerden
    Affiliations
    Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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  • M.C. de Bruijne
    Affiliations
    Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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  • J.G.M. Jelsma
    Affiliations
    Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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  • C.M.J.E. Vandenbroucke-Grauls
    Affiliations
    Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands

    Department of Clinical Medicine – Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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  • R. van Mansfeld
    Affiliations
    Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Open AccessPublished:July 09, 2022DOI:https://doi.org/10.1016/j.jhin.2022.07.005

      Summary

      Background

      Infection control practitioners face several challenges when implementing infection control link nurse (ICLN) programmes. Identification of strategies to address these can improve the impact of current ICLN programmes and guide their future implementation.

      Aim

      We aimed to identify implementation strategies for ICLN programmes in acute-care hospitals with the Consolidated Framework for Implementation Research (CFIR)-Expert Recommendations for Implementing Change (ERIC) Implementation Strategy Matching tool.

      Methods

      An expert panel matched 19 implementation and sustainment barriers, identified in our previous studies, to the most fitting CFIR constructs. Subsequently, we applied the CFIR-ERIC Matching Tool and generated a list of implementation strategies to address these barriers.

      Findings

      Barriers were predominantly found within the CFIR domains ‘inner setting’ (characteristics of the implementing organization) and ‘process’ (stages of implementation). With the ERIC Matching Tool, we identified the 10 most important strategies to address barriers of implementation of ICLN programmes: identify and prepare champions, conduct local consensus discussions, assess for readiness and identify barriers and facilitators, inform local opinion leaders, use facilitation, create a learning collaborative, conduct local needs assessments, develop a formal implementation blueprint, build a coalition, and identify early adopters.

      Conclusion

      The CFIR domains ‘inner setting’ and ‘process’ appeared to be the most important to impede implementation of ICLN programmes in acute-care hospitals. Application of the CFIR-ERIC tool highlighted the identification and preparation of champions as the leading strategy for the successful implementation of these programmes. With this tool, strategies can be specifically tailored towards local implementation and sustainment barriers.

      Keywords

      Introduction

      Infection control link nurses (ICLNs) play a central role in the dissemination and implementation of infection prevention and control measures. Link nurses can observe infection prevention practices on their ward, and inform and instruct their colleagues [
      • Dawson S.J.
      The role of the infection control link nurse.
      ,
      • Dekker M.
      • Mansfeld Rv
      • Vandenbroucke-Grauls C.M.
      • Lauret T.E.
      • Schutijser B.C.
      • de Bruijne M.C.
      • et al.
      Role perception of infection control link nurses; a multi-centre qualitative study.
      ]. ICLNs are supported by programmes that are set up and led by infection control practitioners who provide training and support to establish co-operative relations [
      • Cooper T.
      Delivering an infection control link nurse programme: implementation and evaluation of a flexible teaching approach.
      ,
      • Dekker M.
      • van Mansfeld R.
      • Vandenbroucke-Grauls C.
      • de Bruijne M.
      • Jongerden I.
      Infection control link nurse programs in Dutch acute care hospitals; a mixed-methods study.
      ,
      • Teare E.L.
      • Peacock A.
      The development of an infection control link-nurse programme in a district general hospital.
      ]. Infection control link nurse programmes vary in how they are organized and implemented. This variation relates to all aspects of such programmes, i.e. role description, competences that are required to fulfil the link nurse role and activities for and education of ICLNs [
      • Dekker M.
      • van Mansfeld R.
      • Vandenbroucke-Grauls C.
      • de Bruijne M.
      • Jongerden I.
      Infection control link nurse programs in Dutch acute care hospitals; a mixed-methods study.
      ,
      • Dekker M.
      • Jongerden I.P.
      • van Mansfeld R.
      • Ket J.C.F.
      • van der Werff S.D.
      • Vandenbroucke-Grauls C.
      • et al.
      Infection control link nurses in acute care hospitals: a scoping review.
      ]. Previously, we have shown that infection control practitioners face several challenges when implementing policies with the help of link nurse programmes [
      • Dekker M.
      • van Mansfeld R.
      • Vandenbroucke-Grauls C.
      • de Bruijne M.
      • Jongerden I.
      Infection control link nurse programs in Dutch acute care hospitals; a mixed-methods study.
      ,
      • Dekker M.
      • Jongerden I.P.
      • van Mansfeld R.
      • Ket J.C.F.
      • van der Werff S.D.
      • Vandenbroucke-Grauls C.
      • et al.
      Infection control link nurses in acute care hospitals: a scoping review.
      ,
      • Peter D.
      • Meng M.
      • Kugler C.
      • Mattner F.
      Strategies to promote infection prevention and control in acute care hospitals with the help of infection control link nurses: a systematic literature review.
      ,
      • Ward D.
      Role of the infection prevention and control link nurse.
      ]. Most programmes are often set up and led solely by the infection prevention and control team, without further evaluation [
      • Dekker M.
      • van Mansfeld R.
      • Vandenbroucke-Grauls C.
      • de Bruijne M.
      • Jongerden I.
      Infection control link nurse programs in Dutch acute care hospitals; a mixed-methods study.
      ]. The most common challenges that infection prevention link nurses face include operational difficulties in daily practice (e.g., high workload and low staffing) and no clear definitions of their role and responsibilities [
      • Dawson S.J.
      The role of the infection control link nurse.
      ,
      • Dekker M.
      • Jongerden I.P.
      • van Mansfeld R.
      • Ket J.C.F.
      • van der Werff S.D.
      • Vandenbroucke-Grauls C.
      • et al.
      Infection control link nurses in acute care hospitals: a scoping review.
      ].
      To guide infection control practitioners in the execution of their programmes and to overcome these challenges, it has previously been suggested to teach implementation and personal leadership skills [
      • Dawson S.J.
      The role of the infection control link nurse.
      ,
      • Dekker M.
      • van Mansfeld R.
      • Vandenbroucke-Grauls C.
      • de Bruijne M.
      • Jongerden I.
      Infection control link nurse programs in Dutch acute care hospitals; a mixed-methods study.
      ,
      • Peter D.
      • Meng M.
      • Kugler C.
      • Mattner F.
      Strategies to promote infection prevention and control in acute care hospitals with the help of infection control link nurses: a systematic literature review.
      ], to perform audit and feedback cycles [
      • Dekker M.
      • van Mansfeld R.
      • Vandenbroucke-Grauls C.
      • de Bruijne M.
      • Jongerden I.
      Infection control link nurse programs in Dutch acute care hospitals; a mixed-methods study.
      ,
      • Teare E.L.
      • Peacock A.
      The development of an infection control link-nurse programme in a district general hospital.
      ,
      • Peter D.
      • Meng M.
      • Kugler C.
      • Mattner F.
      Strategies to promote infection prevention and control in acute care hospitals with the help of infection control link nurses: a systematic literature review.
      ], to provide comprehensive role descriptions [
      • Dawson S.J.
      The role of the infection control link nurse.
      ,
      • Ward D.
      Role of the infection prevention and control link nurse.
      ], and to involve ward and hospital management [
      • Dawson S.J.
      The role of the infection control link nurse.
      ,
      • Ward D.
      Role of the infection prevention and control link nurse.
      ]. These approaches, however, have not been grounded in theory. It is therefore not warranted that these suggestions are the most feasible approach or best possible solution with the most desired effect. Suboptimal implementation of ICLN programmes can lead to disappointing effects and will fail to improve practice; the ceasing of ICLN programmes because of failure has been reported [
      • Dawson S.J.
      The role of the infection control link nurse.
      ,
      • Dekker M.
      • van Mansfeld R.
      • Vandenbroucke-Grauls C.
      • de Bruijne M.
      • Jongerden I.
      Infection control link nurse programs in Dutch acute care hospitals; a mixed-methods study.
      ,
      • Ward D.
      Role of the infection prevention and control link nurse.
      ].
      Implementation science focusses on how to improve the uptake of research findings and on how to bridge the gap between evidence-based approaches and daily practice [
      • Nilsen P.
      Making sense of implementation theories, models and frameworks.
      ]. The application of theories, models, or frameworks in intervention design can guide the identification of generalizable approaches and provide a better understanding and explanation of the mechanisms by which implementation succeeds or fails. Implementation science can therefore aid in finding evidence-based strategies for successful planning, adopting and sustaining ICLN programmes [
      • Gilmartin H.M.
      • Hessels A.J.
      Dissemination and implementation science for infection prevention: a primer.
      ]. One of the most cited frameworks in this field, is the Consolidated Framework for Implementation Research (CFIR) [
      • Damschroder L.J.
      • Aron D.C.
      • Keith R.E.
      • Kirsh S.R.
      • Alexander J.A.
      • Lowery J.C.
      Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.
      ]. This theoretical framework incorporates constructs associated with effective implementation from 19 implementation models and theories; it therefore provides a comprehensive overview of the most important theories and conceptual models in implementation research. The CFIR is designed to investigate potential barriers and facilitators, to guide evaluation of an implementation process and can be used to design an implementation plan [
      • Damschroder L.J.
      • Aron D.C.
      • Keith R.E.
      • Kirsh S.R.
      • Alexander J.A.
      • Lowery J.C.
      Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.
      ,
      • Powell B.J.
      • Waltz T.J.
      • Chinman M.J.
      • Damschroder L.J.
      • Smith J.L.
      • Matthieu M.M.
      • et al.
      A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project.
      ,
      • Waltz T.J.
      • Powell B.J.
      • Chinman M.J.
      • Smith J.L.
      • Matthieu M.M.
      • Proctor E.K.
      • et al.
      Expert recommendations for implementing change (ERIC): protocol for a mixed methods study.
      ]. To design such a plan, the CFIR-Expert Recommendations for Implementing Change (ERIC) Implementation Strategy Matching tool can help to select implementation strategies [
      • Waltz T.J.
      • Powell B.J.
      • Chinman M.J.
      • Smith J.L.
      • Matthieu M.M.
      • Proctor E.K.
      • et al.
      Expert recommendations for implementing change (ERIC): protocol for a mixed methods study.
      ]. This tool is based on the CFIR framework and combines constructs from this framework with recommendations for implementation strategies based on expert opinions. It provides an overview of 73 implementation strategies, ranked according to strength or priority for the combination of the barriers that are entered into the tool [
      • Powell B.J.
      • Waltz T.J.
      • Chinman M.J.
      • Damschroder L.J.
      • Smith J.L.
      • Matthieu M.M.
      • et al.
      A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project.
      ,
      • Waltz T.J.
      • Powell B.J.
      • Chinman M.J.
      • Smith J.L.
      • Matthieu M.M.
      • Proctor E.K.
      • et al.
      Expert recommendations for implementing change (ERIC): protocol for a mixed methods study.
      ]. Our study provides relevant implementation strategies based on empirical data on barriers to the implementation of ICLN programmes. In this paper we aimed to provide guidance for better selection of strategies to support the implementation of such programmes in acute-care hospitals.

      Methods

      Design

      We used Delphi techniques to identify which CFIR domains and constructs would fit the barriers to implementing and sustaining ICLN programmes in acute-care hospitals. A Delphi method is an effective method for reaching consensus. It uses at least two rounds of surveys with a panel of experts; each round builds upon the outcomes of the previous one, in an iterative process [
      • Hasson F.
      • Keeney S.
      • McKenna H.
      Research guidelines for the Delphi survey technique.
      ]. In our study, the Delphi rounds were conducted through an online meeting and two e-mail rounds. We explicitly chose this technique to include researchers with specific expertise in infection control and researchers with specific expertise relevant to the CFIR constructs. We considered this expertise important for the clarification of barriers and for the matching of these barriers to the best fitting CFIR controls.
      We applied the CFIR-ERIC Matching Tool to identify implementation strategies.

      Panel members

      The Delphi panel comprised four senior researchers and four junior researchers with expertise in microbiology, infection prevention, nursing, implementation science and quality of care. The panellists were recruited purposefully from research groups on quality and safety and on infection prevention in our hospital. One researcher (M.D.) invited members and organized the meetings, during which she clarified any ambiguities in the description of the barriers and explained the concept of link nurses and ICLN programmes.

      Data collection and analyses

      The consensus meeting and the email rounds were held between April and May 2021.In preparation of the first e -mail round, we operationalized the CFIR domains by describing the first domain, the intervention, as containing the key attributes of an ICLN programme. This also included the perception of other stakeholders of the value of the programme.
      The ‘outer setting’, the second domain of the framework, was operationalized as the context of the hospital at a meta-level, including the degree to which a hospital is linked to other hospitals in its region, the competition with or peer pressure from these hospitals and other external incentives to implement infection prevention and control guidelines. The ‘inner setting’ referred to the structure of the hospital, the dynamics of informal networks and lines of communication, characterizing the implementation climate (e.g., is infection prevention a priority in the hospital) and readiness for implementation (e.g., what indicators underpin the decision to implement a link nurse programme). The fourth domain described the way the individuals are involved in the development and the implementation of a link nurse programme to capture the dynamics between these individuals and the hospital and its influence on the implementation process.
      The fifth domain delineated the planning, execution, reflection and evaluation of the intervention: the process of implementation. Because ICLN programmes are characterized by constant change, this domain reflected the non-linearity of implementing and maintaining a link nurse programme. The different roles of individuals that engage in this process were classified as opinion leaders, formally appointed internal implementation leaders, champions or external change agents.
      We also described the barriers to implementing and sustaining a link nurse programme in acute-care hospitals that we found in the literature and in our previous studies [
      • Dekker M.
      • Mansfeld Rv
      • Vandenbroucke-Grauls C.M.
      • Lauret T.E.
      • Schutijser B.C.
      • de Bruijne M.C.
      • et al.
      Role perception of infection control link nurses; a multi-centre qualitative study.
      ,
      • Dekker M.
      • van Mansfeld R.
      • Vandenbroucke-Grauls C.
      • de Bruijne M.
      • Jongerden I.
      Infection control link nurse programs in Dutch acute care hospitals; a mixed-methods study.
      ,
      • Dekker M.
      • Jongerden I.P.
      • van Mansfeld R.
      • Ket J.C.F.
      • van der Werff S.D.
      • Vandenbroucke-Grauls C.
      • et al.
      Infection control link nurses in acute care hospitals: a scoping review.
      ]. Panel members were e-mailed with an overview of these barriers, inviting them to match these barriers to the most fitting CFIR constructs with the help of the CFIR codebook (https://cfirguide.org/tools/tools-and-templates/). They were also asked to express the rationale for their choices. All panel members returned their answers and comments. With these answers we generated a comprehensive list of possible CFIR constructs, and we prepared slides with an overview of these constructs per barrier. In an online meeting, the panel members reflected on these slides and discussed (dis)agreements and possible root causes for barriers. The operationalization of the CFIR domains helped to guide this discussion. With input from this meeting, we narrowed the list of barriers by compressing and redefining definitions per barrier. These revised descriptions were presented by e-mail and the panel members were asked to consider their previous answers in light of the refined definition and the outcomes of the meeting. If they wished to, they could change the CFIR construct to match a barrier or make further comments. The experts were also asked to confirm that the description of the barriers and their assessment of the CFIR constructs were the final results. One researcher (M.D.) applied the CFIR- ERIC Matching Tool v0.53 (https://cfirguide.org/choosing-strategies/) by entering all identified CFIR constructs into the ERIC tool at once. This tool guides selection of implementation strategies by entering relevant constructs into an Excel form. It then provides a prioritized list of all 73 ERIC implementation strategies, their ranking based on the level of endorsement per barrier reflecting in percentages (higher percentages reflect higher endorsement of the strategy). Strategies are divided into level one strategies (endorsed by ≥50% of the experts) and level two strategies (endorsed by 20–49.9% of the experts). The tool also cumulates the percentages of endorsement for all entered barriers. In this way strategies that can address multiple barriers simultaneously are identified. The tool does not operationalize these strategies. We discussed the application and interpretation of the proposed ERIC strategies within the research team (M.D., R.M., I.P.J., C.M.J.E.V.G., M.C.B). We chose to present the 10 strategies with the highest endorsement. This way we included the strategies with the strongest recommendations. We operationalized these strategies by combining the definitions of the CFIR constructs with the definitions of the level one and level two recommended ERIC strategies and specified these narratives with ICLN programmes in mind [
      • Powell B.J.
      • Waltz T.J.
      • Chinman M.J.
      • Damschroder L.J.
      • Smith J.L.
      • Matthieu M.M.
      • et al.
      A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project.
      ,

      Consolidated Framework for Implementation Research. Available at: https://cfirguide.org/constructs/[last accessed May 2021].

      ]. To identify barrier-specific ERIC strategies we repeated the application of the tool, and entered the CFIR constructs that were matched to each individual barrier. We defined the top five strategies per barrier correspondingly.

      Results

      CFIR barriers

      In our previous studies, we identified 19 barriers [
      • Dekker M.
      • Mansfeld Rv
      • Vandenbroucke-Grauls C.M.
      • Lauret T.E.
      • Schutijser B.C.
      • de Bruijne M.C.
      • et al.
      Role perception of infection control link nurses; a multi-centre qualitative study.
      ,
      • Dekker M.
      • van Mansfeld R.
      • Vandenbroucke-Grauls C.
      • de Bruijne M.
      • Jongerden I.
      Infection control link nurse programs in Dutch acute care hospitals; a mixed-methods study.
      ,
      • Dekker M.
      • Jongerden I.P.
      • van Mansfeld R.
      • Ket J.C.F.
      • van der Werff S.D.
      • Vandenbroucke-Grauls C.
      • et al.
      Infection control link nurses in acute care hospitals: a scoping review.
      ]. In the first e-mail round, all eight panel members mapped individually the most fitting CFIR constructs to these barriers. Only two of the barriers were mapped by all members to the same CFIR construct. All panel members attended the 2-h long online meeting. During the meeting, it became clear that some of the barriers were described too briefly, some of the barriers had the same root cause, and for some barriers more background information was needed. For example, the panel discussed several barriers that link nurses experienced in the uptake of their role at the ward level. These were a lack of support from ward management, insufficient time for link nurse activities and a lack of power that was allotted to the link nurse role. The panel concluded that these three barriers could be summarized as one main barrier with several root causes, namely, the low priority of infection prevention at the hospital management level. During the meeting, consensus was reached on the CFIR constructs that best fitted each barrier. For one main barrier, consensus was reached on one CFIR construct. The other six main barriers could be explained by several conditions or underlying root causes. For these barriers, the panel chose the most eligible CFIR constructs, with a maximum of five. This strategy was chosen to generate implementation strategies that would address various root causes and therefore be broadly applicable. With the input from the panel, the 19 barriers were redefined and grouped into seven main barriers (Table I). In the last round, all panel members agreed on the definitions of barriers and accompanying CFIR constructs. The barriers corresponded predominantly with CFIR constructs from the domains ‘inner setting’ (characteristics of the implementing organization) and ‘process’ (stages of implementation). None of the barriers corresponded with constructs from the domain ‘outer setting’ (external influences on the implementation).
      Table IBarriers to the implementation of an infection control link nurse (ICLN) programme and their matching Consolidated Framework for Implementation Research (CFIR) constructs
      BarrierWhy is this a barrier?CFIR domainCFIR construct
      Infection control has no priority at the hospital levelThere were other priorities at the hospital level (e.g., hospital merger) which resulted in the ceasing of link nurse programmesInner settingRelative priority

      Tension for change
      A lack of time and power (mandate) was allotted to link nurses which resulted in the ceasing of link nurse programmesInner settingLeadership engagement

      Relative priority
      A lack of support from ward management to acknowledge and validate the link nurse role to the rest of the team, e.g., when peers resist compliance with infection control policies. Link nurses felt their role was undermined when this support was not in placeInner settingLeadership engagement
      Operational difficulty at the individual level – high workload and low staffing leaving insufficient time for link nurse activitiesInner settingAvailable resources
      The role of link nurses is not definedAt the hospital level, a written role profile is essential for clarity, expectations of link nurses for all stakeholders, and to facilitate communication on the role and tasks within the organization

      At the individual level, a role profile is essential to facilitate link nurses in the uptake and ownership of their role
      Intervention characteristicsDesign quality and packaging
      The uptake of the link nurse role is experienced as challenging by some link nurses; they do not know where to start, what issues to address or how to shape their activities. For some ICLNs, the uptake remains complex even with the help of a written role profileIntervention characteristics

      Characteristics of individuals
      Design quality and packaging

      Self-efficacy

      Individual stage of change
      ICLNs are not accepted by medical staffThe lack of acceptance of the link nurse role by other groups of healthcare workers may limit the influence of link nurses in their departments. A study showed that nurses found it difficult to address some of the medical staff because of their seniority and status and to avoid conflict and confrontationInner setting

      Process

      Characteristics of individuals
      Learning climate

      Culture

      Opinion leaders

      Knowledge and beliefs about the intervention
      ICLN programmes are initiated, developed and implemented solely by infection control practitionersNot all infection control practitioners have a priori knowledge on how to develop complex interventions and guide their implementation Most ICLN programmes are developed while implemented which could result in an incomplete plan-do-study-act (PDSA)cycle.Intervention characteristics

      Process

      Characteristics of individuals
      Design quality and packaging

      Planning

      Executing

      Self-efficacy

      Individual stage of change
      Responsibility to educate link nurses lies with infection control practitionersICLN programmes are initiated and implemented bottom-up by the infection control team. There is variation in which stakeholders are involved. This could result in a lack of support for the programme and impede multi-disciplinary collaborations with experts in implementation and educationProcessEngaging

      Key stakeholders

      Formally appointed internal implementation leaders
      Education for ICLNs varies widely. Programmes that provide education on infection prevention topics and include training in implementation skills are perceived as more effective programmes without education or programmes where education included only infection prevention topicsIntervention characteristics

      Process
      Design quality and packaging

      Key stakeholders
      ICLN programmes vary in the way they support their ICLNs. Link nurses expressed the availability and accessibility of an infection control practitioner as a precondition to fulfil their role. When this support was not readily available, Iink nurses felt hindered in the execution of their role and questioned the importance of their initiatives. Therefore, a proactive infection control practitioner is a prerequisite for implementationProcess

      Characteristics of individuals
      Opinion leaders

      Champions

      Self-efficacy

      Individual stage of change
      Interconnecting link nurses from various departments to exchange experiences and best practices is challengingLink nurses report the need to collaborate with other link nurses but do not initiate such collaborationsInner settingCompatibility

      Networks & communication
      Only half of link nurse programmes are evaluatedThere is no formal evaluation of ICLN programmes on structure, process and outcome indicators. Evaluation of efforts focus on the satisfaction of link nurses with the programme. Some infection control practitioners reported positive effects based on random observations during ward rounds and gut feelingProcessReflecting & evaluating

      ERIC strategies

      The CFIR-ERIC matching tool provided a list of implementation strategies to address all seven barriers to implementation at once. The top 10 strategies to overcome these barriers are listed in order of priority in Table II. The strategy with highest cumulative value of percentages in the ERIC tool, which reflected the highest endorsement by the panel of experts, was to identify and prepare champions. This single strategy will address five constructs with a level one recommendation, eight constructs with a level two recommendation, and can address five of the identified main barriers.
      Table IITop 10 implementation strategies based on the Consolidated Framework for Implementation Research (CFIR)-Expert Recommendations for Implementing Change (ERIC) tool
      CFIR constructsCumulative value of percentagesDesign quality & packagingNetworks & communicationsCultureTension for changeCompatibilityRelative priorityLearning climateLeadership engagementAvailable resourcesKnowledge & beliefs about the interventionSelf-efficacyIndividual stage of changePlanningOpinion leadersFormally appointed internal implementation leadersChampionsKey stakeholdersExecutingReflecting & evaluating
      ERIC strategies
      Identify and prepare champions670151752482118314144030443164646763148
      Conduct local consensus discussions4392622224341462727012020233214264278
      Assess for readiness and identify barriers and facilitators4367134135343619141320111242142915383112
      Inform local opinion leaders38719222239314191802842805729442938
      Facilitation3637263002414541842022823112119172420
      Create a learning collaborative3137353091441559163028811141933218
      Conduct local needs assessment3101592243213219140240050141172134
      Develop a formal implementation blueprint3061513713314122344114730461182816
      Build a coalition30103919921181918171601643211302508
      Identify early adopters3001117111310712902019241243254113140
      Level 1 endorsements in dark grey, level 2 endorsements in light grey. Endorsements in % represent the proportion of panel participants that recommend the strategy for that specific barrier.

      Strategy 1: identify and prepare champions

      Champions are individuals that have informal influence and actively support the link nurse programme during implementation. They can help overcome resistance that may hamper the implementation, shift the perception of key stakeholders and influence individuals in an organization who formally or informally influence the attitudes and beliefs of their colleagues with respect to the implementation of the ICLN programme. Champions can influence the organizational culture, a critical barrier to leveraging infection prevention knowledge and implementing an ICLN programme.

      Strategy 2: conduct local consensus discussions

      To reach consensus about the importance of infection prevention and about the appropriateness of an ICLN programme, the risks of poor infection prevention can be discussed with key stakeholders and local providers (e.g., hospital and ward managers and nurses). These discussions can add to the degree to which stakeholders perceive the need for an ICLN programme, to change or implement infection control practices in the hospital, and to the perception of the importance of infection prevention in the organization.

      Strategy 3: assess for readiness and identify barriers and facilitators

      A thorough assessment of several aspects of the hospital, such as the availability of resources and staff, of the attitudes of stakeholders and of leadership support and of former successful quality improvements techniques, can help to determine if the hospital is ready for the implementation of an ICLN programme, to identify the local barriers that can impede its implementation and the strengths that can leverage or facilitate the link nurse programme. It will help to design an implementation plan with actions to promote the effective implementation. It will help to build local capacity to adopt the ICLN programme and it can influence the organizational culture.

      Strategy 4: inform local opinion leaders

      When formally appointed with the responsibility to implement an ICLN programme, as coordinator, project manager or team leader, an infection control practitioner can inform individuals within the hospital who have formal or informal influence (i.e. opinion leaders) about the ICLN programme.

      Strategy 5: facilitation

      Infection control practitioners can support link nurses and wards in their effort to adopt and incorporate the link nurse role within their daily practice. This interactive support process typically combines multiple strategies such as enabling and problem solving. It can contribute to a learning climate at the hospital and at the ward level. Within a learning climate the link nurse's input to implement infection prevention practices is validated by the management and by healthcare workers within the hospital. It will help to accept the ICLN role and for the ICLN to feel valued.

      Strategy 6: create a learning collaborative

      Infection control practitioners can facilitate a collaborative learning environment for ICLNs to help them to implement infection prevention practices. A link nurse programme can include a peer consultation network, an online community of practice or a quality circle. ICLNs may meet in person or interact using a wide variety of media. This will facilitate the connections and bonding between the infection control practitioner and the ICLNs. It will build a community that contributes to the implementation of infection prevention. At the individual level it will strengthen ICLNs' knowledge, skills, enthusiasm, and their belief in their own capability to fulfil the link nurse role within the specific context of their ward.

      Strategy 7: conduct local needs assessments

      Before implementing an ICLN programme, infection control practitioners can assess process and outcome measures related to infection prevention at the hospital level. At the ward level, wards can be approached to identify whether there is a need for a link nurse programme and potential considerations for specific elements within the link nurse programme. Methods of performing a local needs assessment can include the use of audit data, data mining of administrative records, and qualitative methods such as interviews or focus groups with stakeholders of several wards. The assessment will help to plan and develop a programme in advance and add to the quality of the programme. It will also add to the tension for change, the degree to which the stakeholders perceive the hospital is in need of an ICLN programme, or their ward is in need of an ICLN to change or implement infection control practices.

      Strategy 8: develop a formal implementation blueprint

      A formal implementation blueprint is a plan that includes the purpose and scope of the programme, a time-frame with milestones and a plan to measure its progress and outcomes. This plan helps the infection control practitioners to guide the ICLN programme and its implementation; it should be updated along the way. It will also make clear to the wards what to expect when they adopt the programme and appoint a link nurse.

      Strategy 9: build a coalition

      Infection control practitioners should invest in relationships and their connections with individual colleagues, wards and services to build a community or team spirit. A strong social network and the quality of formal and informal communications within the hospital may contribute to the effect of an ICLN programme. Cultivating these relationships can also help to identify opinion leaders and champions.

      Strategy 10: identify early adopters

      Infection control practitioners can learn from the experience of wards and link nurses that adopt the programme from the start of implementation. These wards and individual link nurses can help the implementation by sharing their experiences with key stakeholders.

      Barrier-specific ERIC strategies

      Table III provides a summary of the top five ERIC strategies that specifically address each main barrier to the implementation of an ICLN programme. The strategies are ranked listed in order of priority. The operationalization of the additional strategies can be found in the Supplementary data.
      Table IIIBarrier-specific implementation strategies
      BarrierERIC-endorsed implementation strategies
      Infection control has no priority at the hospital levelConduct local consensus discussions; identify and prepare champions; alter incentive/allowance structures; access new funding; assess for readiness and identify barriers and facilitators
      The role of link nurses is not definedMake training dynamic; identify and prepare champions; promote adaptability; develop educational materials; create a learning collaborative
      ICLNs are not accepted by medical staffIdentify and prepare champions; inform local opinion leaders; conduct educational meetings; facilitation; assess for readiness and identify barriers and facilitators
      ICLN programmes are initiated, developed and implemented solely by infection control practitionersIdentify and prepare champions; develop a formal implementation blueprint; conduct ongoing training; assess for readiness and identify barriers and facilitators; develop and implement tools for quality monitoring
      Responsibility to educate link nurses lies with infection control practitionersIdentify and prepare champions; inform local opinion leaders; identify early adopters; conduct local consensus discussions; create a learning collaborative
      Interconnecting link nurses from various departments to exchange experiences and best practices is challengingOrganize clinician implementation team meetings; conduct local consensus discussions; build a coalition; promote network weaving; facilitation
      Only half of link nurse programmes are evaluatedDevelop and implement tools for quality monitoring; audit and provide feedback; develop and organize quality monitoring systems; facilitate relay of clinical data to providers; obtain and use patients/consumers and family feedback
      ERIC, Expert Recommendations for Implementing Change; ICLN, infection control link nurse.

      Discussion

      Barriers that may affect the efforts of infection control practitioners to implement a link nurse programme require careful consideration. This study highlights the major importance of characteristics of the implementing organization and the stages of implementation; these are the implementation research domains ‘inner setting’ and ‘process’. These two domains appear as main influencers of successful implementation of link nurse programmes to improve infection prevention in acute-care hospitals. Application of the CFIR-ERIC tool provides several key insights regarding the strategies to guide the implementation of these programmes. First, the most prominent strategy is the identification and preparation of champions. This single strategy addresses multiple barriers in the ‘inner setting’ and in the ‘process’ domain (e.g., lack of priority for infection prevention, lack of acceptance of the link nurse role, variation in support for link nurse) by cultivating commitment, reducing resistance and fostering tension for change. The importance of champions is underlined by previous research that emphasizes the importance of leadership engagement and influential roles when implementing quality or health improvement initiatives [
      • Clack L.
      • Zingg W.
      • Saint S.
      • Casillas A.
      • Touveneau S.
      • da Liberdade Jantarada F.
      • et al.
      Implementing infection prevention practices across European hospitals: an in-depth qualitative assessment.
      ,
      • Zingg W.
      • Holmes A.
      • Dettenkofer M.
      • Goetting T.
      • Secci F.
      • Clack L.
      • et al.
      Hospital organisation, management, and structure for prevention of health-care-associated infection: a systematic review and expert consensus.
      ,
      • Damschroder L.J.
      • Lowery J.C.
      Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR).
      ]. The role of champions also aligns with our earlier suggestions to involve key stakeholders to support the programme and the link nurses at the hospital and ward level [
      • Dekker M.
      • Mansfeld Rv
      • Vandenbroucke-Grauls C.M.
      • Lauret T.E.
      • Schutijser B.C.
      • de Bruijne M.C.
      • et al.
      Role perception of infection control link nurses; a multi-centre qualitative study.
      ,
      • Dekker M.
      • Jongerden I.P.
      • van Mansfeld R.
      • Ket J.C.F.
      • van der Werff S.D.
      • Vandenbroucke-Grauls C.
      • et al.
      Infection control link nurses in acute care hospitals: a scoping review.
      ]. Champions, individuals that have informal influence, can help to overcome resistance that may hamper the adoption or the implementation of a link nurse programme within the hospital when they actively support the intervention during implementation [
      • Hasson F.
      • Keeney S.
      • McKenna H.
      Research guidelines for the Delphi survey technique.
      ]. To identify champions, Warrick recommends starting by identifying a few individuals throughout the hospital that already have the reputation of being a champion [
      • Warrick D.
      Developing organization change champions.
      ]. This identification can be facilitated by self-nomination or peer-nomination because sustained commitment is important during the adoption and implementation phase [
      • Bunce A.E.
      • Gruß I.
      • Davis J.V.
      • Cowburn S.
      • Cohen D.
      • Oakley J.
      • et al.
      Lessons learned about the effective operationalization of champions as an implementation strategy: results from a qualitative process evaluation of a pragmatic trial.
      ,
      • Soo S.
      • Berta W.
      • Baker G.R.
      Role of champions in the implementation of patient safety practice change.
      ]. There is no consensus in the literature on how to effectively prepare champions for their role; in addition, the way in which the champions role is operationalized can differ [
      • Miech E.J.
      • Rattray N.A.
      • Flanagan M.E.
      • Damschroder L.
      • Schmid A.A.
      • Damush T.M.
      Inside help: an integrative review of champions in healthcare-related implementation.
      ]. Bonawitz and colleagues suggest that the skills of effective champions can be learned [
      • Bonawitz K.
      • Wetmore M.
      • Heisler M.
      • Dalton V.K.
      • Damschroder L.J.
      • Forman J.
      • et al.
      Champions in context: which attributes matter for change efforts in healthcare?.
      ]. Others indicate that some qualities and competences cannot be taught [
      • Bunce A.E.
      • Gruß I.
      • Davis J.V.
      • Cowburn S.
      • Cohen D.
      • Oakley J.
      • et al.
      Lessons learned about the effective operationalization of champions as an implementation strategy: results from a qualitative process evaluation of a pragmatic trial.
      ,
      • Miech E.J.
      • Rattray N.A.
      • Flanagan M.E.
      • Damschroder L.
      • Schmid A.A.
      • Damush T.M.
      Inside help: an integrative review of champions in healthcare-related implementation.
      ,
      • Shaw E.K.
      • Howard J.
      • West D.R.
      • Crabtree B.F.
      • Nease Jr., D.E.
      • Tutt B.
      • et al.
      The role of the champion in primary care change efforts: from the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP).
      ]. Sustained and enthusiastic advocation of the programme, communicating the purpose and scope of the programme, convincing others that the intervention is important and worthwhile, and leading by example are successful behaviours of champions that support implementation of quality improvement interventions in various healthcare settings [

      Consolidated Framework for Implementation Research. Available at: https://cfirguide.org/constructs/[last accessed May 2021].

      ,
      • Bunce A.E.
      • Gruß I.
      • Davis J.V.
      • Cowburn S.
      • Cohen D.
      • Oakley J.
      • et al.
      Lessons learned about the effective operationalization of champions as an implementation strategy: results from a qualitative process evaluation of a pragmatic trial.
      ,
      • Soo S.
      • Berta W.
      • Baker G.R.
      Role of champions in the implementation of patient safety practice change.
      ,
      • Miech E.J.
      • Rattray N.A.
      • Flanagan M.E.
      • Damschroder L.
      • Schmid A.A.
      • Damush T.M.
      Inside help: an integrative review of champions in healthcare-related implementation.
      ,
      • Shaw E.K.
      • Howard J.
      • West D.R.
      • Crabtree B.F.
      • Nease Jr., D.E.
      • Tutt B.
      • et al.
      The role of the champion in primary care change efforts: from the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP).
      ]. These attributes should be kept in mind when searching for champions.
      Second, the key barriers in the ‘process’ domain relate to the somewhat improvident approach of link nurse programme implementation. ICLN programmes often start with and get stuck in the ‘do’ phase, reflecting poor planning, engaging and failing to monitor and evaluate the effects of the programme [
      • Dekker M.
      • van Mansfeld R.
      • Vandenbroucke-Grauls C.
      • de Bruijne M.
      • Jongerden I.
      Infection control link nurse programs in Dutch acute care hospitals; a mixed-methods study.
      ,
      • Reed J.E.
      • Card A.J.
      The problem with Plan-Do-Study-Act cycles.
      ]. Several ERIC strategies can be used to improve this approach and help to shape an ICLN programme Plan-Do-Study-Act cycle. A new insight provided by the matching tool, e.g., is the use of needs assessments [
      • Powell B.J.
      • Fernandez M.E.
      • Williams N.J.
      • Aarons G.A.
      • Beidas R.S.
      • Lewis C.C.
      • et al.
      Enhancing the impact of implementation strategies in healthcare: a research agenda.
      ]. This is an important strategy that will inform and provide input during the planning phase, and adds to the formation of the implementation plan and programme blueprint. As an additional strategy, Perry et al. advise the discussion of these plans with stakeholders to obtain feedback [
      • Perry C.K.
      • Damschroder L.J.
      • Hemler J.R.
      • Woodson T.T.
      • Ono S.S.
      • Cohen D.J.
      Specifying and comparing implementation strategies across seven large implementation interventions: a practical application of theory.
      ]. Infection control practitioners could benefit from this strategy by incorporating these needs assessments and obtaining stakeholder feedback in their Plan-Do-Study-Act cycle. Iteratively assessing the needs of wards, being open to change and refining the link nurse programme and the strategies for its implementation will increase the chance of success [
      • O'Cathain A.
      • Croot L.
      • Duncan E.
      • Rousseau N.
      • Sworn K.
      • Turner K.M.
      • et al.
      Guidance on how to develop complex interventions to improve health and healthcare.
      ]. To measure success, it is important to monitor implementation quality as well as the effects on infection prevention measures and outcomes [
      • O'Cathain A.
      • Croot L.
      • Duncan E.
      • Rousseau N.
      • Sworn K.
      • Turner K.M.
      • et al.
      Guidance on how to develop complex interventions to improve health and healthcare.
      ,
      • Moore G.F.
      • Audrey S.
      • Barker M.
      • Bond L.
      • Bonell C.
      • Hardeman W.
      • et al.
      Process evaluation of complex interventions: Medical Research Council guidance.
      ].
      The role of the infection control practitioner as a key stakeholder in the implementation of ICLN programmes has not been described in previous literature. Therefore, a third important implementation strategy to consider is to invest in facilitation; this comprises both a strategy and a role for the infection control practitioner [
      • Perry C.K.
      • Damschroder L.J.
      • Hemler J.R.
      • Woodson T.T.
      • Ono S.S.
      • Cohen D.J.
      Specifying and comparing implementation strategies across seven large implementation interventions: a practical application of theory.
      ]. By providing support, an infection control practitioner can enable link nurses and wards to implement infection prevention policies. Facilitation is complex as the support should be tailored to the local needs of each ward and link nurse. Thus, the infection control practitioner should be able to consciously choose from various support strategies, methods or techniques and balance the level and intensity of their support [
      • Berta W.
      • Cranley L.
      • Dearing J.W.
      • Dogherty E.J.
      • Squires J.E.
      • Estabrooks C.A.
      Why (we think) facilitation works: insights from organizational learning theory.
      ]. Therefore, infection control practitioners should master a range of competences. Key attributes to facilitation are interpersonal skills (e.g., flexibility, tact and sensitivity), skill in communication (e.g., conflict management and negotiation), skills in leadership (e.g., strategic thinking, responsiveness and commitment), skills in project management and skills in education [
      • Dogherty E.J.
      • Harrison M.B.
      • Graham I.D.
      Facilitation as a role and process in achieving evidence-based practice in nursing: a focused review of concept and meaning.
      ,
      • Harvey G.
      • Loftus-Hills A.
      • Rycroft-Malone J.
      • Titchen A.
      • Kitson A.
      • McCormack B.
      • et al.
      Getting evidence into practice: the role and function of facilitation.
      ,
      • Lessard S.
      • Bareil C.
      • Lalonde L.
      • Duhamel F.
      • Hudon E.
      • Goudreau J.
      • et al.
      External facilitators and interprofessional facilitation teams: a qualitative study of their roles in supporting practice change.
      ,
      • Taylor E.F.
      • Machta R.M.
      • Meyers D.S.
      • Genevro J.
      • Peikes D.N.
      Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers.
      ].
      A strength of the current study is that previously mentioned barriers regarding implementation of link nurse programmes were discussed among a Delphi panel and mapped on a relatively new tool developed by implementation experts worldwide. However, Delphi panels do not provide right or wrong answers and consensus does not mean the correct answer is given. Furthermore, the effectivity of strategies that the CFIR-ERIC tool produces have not been broadly evaluated and should be tested to show if sufficient to guide local implementation efforts [
      • Fernandez M.E.
      • Ten Hoor G.A.
      • van Lieshout S.
      • Rodriguez S.A.
      • Beidas R.S.
      • Parcel G.
      • et al.
      Mapping: using intervention mapping to develop implementation strategies.
      ]. Therefore, we recommend that each hospital should develop an implementation strategy, based on barrier-specific ERIC strategies as found in our study, and should include experts in the prioritization and operationalization of the strategies. For further operationalization of these implementation strategies, it is advised to follow the reporting guidelines from Powell et al., whereby the actor, action, target, temporality, dose, implementation outcome affected and justifications are specified [
      • Proctor E.K.
      • Powell B.J.
      • McMillen J.C.
      Implementation strategies: recommendations for specifying and reporting.
      ]. Future research should investigate the process of selecting and tailoring these strategies in various contexts and should test these strategies themselves.
      This study highlighted the CFIR domains ‘inner setting’ and ‘process’ as influential on infection prevention guideline implementation with the help of link nurse programmes in acute-care hospitals. Application of the CFIR-ERIC tool points to the identification and preparation of champions as the leading strategy to lever the implementation of ICLN programmes. Our findings can help implementation planning efforts when starting an ICLN programme but cannot substitute the context-specific analysis of implementation needs. Further strategies can be tailored to various clinical contexts with the help of the identified barriers and the use of the tool.

      Acknowledgements

      We gratefully acknowledge all panellists for their contributions and time.

      Conflict of interest statement

      None declared.

      Funding sources

      This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

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