PHASE 3: IMPLEMENTATION

To ensure that acupuncture / acupressure is implemented, both inner enablers and outside enablers are needed. Inner factors have five main domains, such as organisation characteristics, network and communication, climate for change and readiness for change; and outer factors have four domains, such as patient needs, peer pressure, network of the organisation and external policy. A list of some key factors to be considered and addressed during implementation is explained in this section. Also included here is a list of implementation strategies to address various barriers.

Select any of the following categories to continue:

Structure

Priority and Goals

Implementation Strategies

Training

Engaging Management

Assess

Execute the Implementation

Structure of the Organisation

Under CFIR, this refers to structure of the organisation (“Structural Characteristics”). Under this, the interrelationship of the organisation is also discussed in relevance to the implementation. Depending on how the implementation is planned, and what is implemented, the number of departments, or types of health professionals involved, will vary.

For instance, if acupuncture is administered once prior to surgery, then no other departments are involved in the implementation of this intervention. However if acupressure is used for 24 hours peri-surgically, then staff from admission, theatre, recovery to the wards will be involved in some part of the implementation. The coordination and communication among those units are essential.

The key solution will be to ensure all key stakeholders are part of the team.

Priority and Goals

Under CFIR, this refers to individual clinician’s priority and goals , and if they are aligned with the implementation and associated changes. It is considered a stronger predictor of the effectiveness of implementation.

It is therefore essential to communicate the implementation goals to staff, and to give feedback that is aligned with staff goals.

Implementation Strategies

A key part of implementation is knowledge translation, which enables all stakeholders to understand why, what, by whom and how an intervention is implemented. Here is an extract from Grimshaw’s 2012 review on various implementation strategies and their effectiveness (Grimshaw et al., 2012). This table also contains examples on how those strategies can be used for Acupressure for PONV.

Strategies	Expected effectiveness from the Literature	Example strategies for Acupressure for PONV
Strategies focussed on Health professionals
Printed educational material	4.3% (-8.0% to 9.6%)	Leaflet about risk factors of PONV, relationship between risk and risk factors and evidence for acupressure will be distributed among staff members.
Educational meetings	6% (+1.8% to 15.3%)	Team members will go to various departments to present the information to conduct education. This will be regularly conducted about once every three months. Two focus meetings will be arranged and invite all from the hospital to attend. This will enable cross-discipline interaction at the meeting.
Education outreaching	4.8% (3.0% to 6.5%)	Researchers on the team will meet individuals who would like to know more about the project.
Local opinion leaders	12% (6% to 14.5%)	This is the most effective strategy and will be the key method in the project. Clinical team members of this study will be the local opinion leaders. And new opinion leaders will also be identified during the study period. Opinion leaders can be department heads and keen and interested staff members.
Audit and feedback	5% (3% to 11%)	Monthly audit will be conducted and results will be feedback to staff members.
Computerised reminder	N/A
Tailored strategies		Training the capability of staff in delivering acupressure
Strategies focusing on patients
Communication before consultation / written information	Data not available	Handout about acupressure in multiple languages will be sent with surgery booking information to all patients who undertake elective surgery. Patients are encouraged to discuss the use of acupressure with their surgeons and the research team.
Communicate personalised risk and facilitate decision making	Data not available	All relevant staff members are notified of the PONV risks and selection criteria for patients who are suitable for acupressure. At the consultation with the surgeon, patients are informed of their risk of PONV and pros and cons of acupressure.

The Expert Recommendations for Implementing Change (ERIC) has compiled 73 implementation strategies (https://cfirguide.org/choosing-strategies/) and CFIR has mapped them to CFIR construct and developed “CFIR-ERIC Matching Tool v1.0”. Promoting adaptability, accessing new funds, involving patients and family and others have been identified as key strategies.

Training

Under CFIR, training is under “Access to knowledge and information“. Easy access to information and on-the-job-training is a step to facilitate behavioural changes.

In addition, different training material may be developed due to varied roles of each unit plays in the implementation. The Acupressure for PONV study has three training packages: one for nurses who assess risk and apply acupressure, one for nurses in Recovery and on the ward who will record the application and may need to re-apply acupressure, and one for patients on how to re-apply acupressure. On the job training was provided one week per month for two months to nurses who assess PONV risk and apply acupressure until the behaviours have been normalised.

Engaging Management

This is related to Leadership Engagement under CFIR. It refers to the “commitment, involvement, and accountability of leaders and managers”. Managers or leaders range from those at the executive level, middle level to those at the front line or team. Without their support, no implementation could be successful. Their support offers motivation to staff through persuasion and modelling, provides opportunities through sourcing resources and setting priorities, and builds capability through encouraging and organising education sessions. Using Acupressure for PONV as an example, hospital management supports the practice of improving patient experience, and encourages staff to take part in research; middle managers are keen to see improved patient outcomes with non-pharmacological interventions and to offer patients a choice.

Aligning the implementation with organisation goals and involving management from the early stages of discussion and priority setting is the key.

Assess

This is related to Reflecting and evaluating under CFIR. Key outcome measures need to be defined at the start of the implementation; as well as methods to track those outcome measures. Regular feedback should be given to the staff to improve their performance.

Audit is a commonly used method to assess performance. It can be compared with data collected at preparation stage (pre-implementation). Please see a data collection example here. Here is Joanna Briggs Institute online Audit tool “PACES” to help the auditing process. Please note login is required.

Execute the Implementation

The above-mentioned items help the development of an implementation plan, including barriers, enablers, strategies to address those barriers, identifying roles, the goals for behaviour changes, performance evaluation systems, performance feedback systems, and a dynamic plan for addressing arising issues.

In CFIR, this is under “Execute”. It is helpful to adopt some strategies leading to a better implementation. These strategies include

A practice run
A pilot implementation
Step-approach implementation. For instance, implementing acupressure in patients with certain surgeries; or implementing one part of the complex intervention first; or limiting interventions to one unit and track their performance first.