implementation of clinical practice changes in the picu: a

RESEARCH Open Access

Implementation of clinical practice changesin the PICU: a qualitative study using andrefining the iPARIHS frameworkKatherine M. Steffen1* , Laura M. Holdsworth2, Mackenzie A. Ford3, Grace M. Lee4, Steven M. Asch5 andEnola K. Proctor6

Abstract

Background: Like in many settings, implementation of evidence-based practices often fall short in pediatricintensive care units (PICU). Very few prior studies have applied implementation science frameworks to understandhow best to improve practices in this unique environment. We used the relatively new integrated PromotingAction on Research Implementation in Health Services (iPARIHS) framework to assess practice improvement in thePICU and to explore the utility of the framework itself for that purpose.

Methods: We used the iPARIHS framework to guide development of a semi-structured interview tool to examinebarriers, facilitators, and the process of change in the PICU. A framework approach to qualitative analysis, developedaround iPARIHS constructs and subconstructs, helped identify patterns and themes in provider interviews. Weassessed the utility of iPARIHS to inform PICU practice change.

Results: Fifty multi-professional providers working in 8 U.S. PICUs completed interviews. iPARIHS constructs shapedthe development of a process model for change that consisted of phases that include planning, a decision toadopt change, implementation and facilitation, and sustainability; the PICU environment shaped each phase. Large,complex multi-professional teams, and high-stakes work at near-capacity impaired receptivity to change. While theunit leaders made decisions to pursue change, providers’ willingness to accept change was based on the evidencefor the change, and provider’s experiences, beliefs, and capacity to integrate change into a demanding workflow.Limited analytic structures and resources frustrated attempts to monitor changes’ impacts. Variable providerengagement, time allocated to work on changes, and limited collaboration impacted facilitation. iPARIHS constructswere useful in exploring implementation; however, we identified inter-relation of subconstructs, unique conceptsnot captured by the framework, and a need for subconstructs to further describe facilitation.

Conclusions: The PICU environment significantly shaped the implementation. The described process model forimplementation may be useful to guide efforts to integrate changes and select implementation strategies. iPARIHSwas adequate to identify barriers and facilitators of change; however, further elaboration of subconstructs forfacilitation would be helpful to operationalize the framework.

Trial registration: Not applicable, as no health care intervention was performed.

Keywords: Clinical practice change, Implementation, Intensive care unit, Pediatric

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected] of Pediatrics, Division of Pediatric Critical Care Medicine,Stanford University, 770 Welch Road, Suite 435, Palo Alto, CA 94304, USAFull list of author information is available at the end of the article

Steffen et al. Implementation Science (2021) 16:15 https://doi.org/10.1186/s13012-021-01080-9

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Contributions to the literature

� This analysis identifies common barriers and facilitators of

practice change in the PICU, which may inform

implementation of future evidence-based interventions in

this care setting.

� Limited research has applied the iPARIHS framework,

although the parent PARIHS is widely cited. This study adds

to the literature by using this new framework to address

implementation planning and strategy selection in the PICU.

� We noted limitations of the iPARIHS framework, particularly

around the facilitation construct, but provide descriptions of

useful activities that may improve understanding and

specification of facilitation.

BackgroundAdvances in care for critically ill children have improvedoutcomes. However, too often modern medical caretrades reduced mortality for increased morbidity inpediatric intensive care units (PICUs) [1]. One contrib-uting reason is that existing evidence-based practices areoften not used as frequently as recommended. As inmany health care settings, implementation of evidencein the intensive care unit (ICU) presents challenges,some of which may be due to patient complexity, stress,and an increased risk for error [2]. Moreover, specificchallenges to implementation related to the pediatricpopulation and environmental context of the PICU mayalso exist.Adult ICU studies provide some insight into ICU-

specific implementation issues, but often focus on imple-mentation of a specific intervention [3–7] such as post-arrest care [8], ICU care bundles [9], or handoffs [10], orutilize a specific implementation approach [2, 5, 11].Prior studies report that identifying and addressing local,contextual implementation barriers may help tooptimize care delivery in the ICU [12–14], which includelack of awareness of the innovation/guideline [7, 15],lack of resources [11], competing priorities [11], appre-hension around change [7], poor formatting of theinnovation for the clinical context [7], and inability toprovide accurate feedback on performance [11]. Sinuffet al. noted a fundamental need for an ICU culture tosupport a new intervention [16]. Other studies identifiedengaging staff, education, providing adequate time andresources, reminders, audit and feedback, and datareporting on performance as being useful implementa-tion strategies [5, 6, 8, 9, 15, 16], with providers in differ-ent roles reporting different implementation strategiesmost useful in effecting change [15].

While adult ICU studies may begin to inform imple-mentation of clinical practice changes in the PICU, toour knowledge, no study has attempted to characterizeunique PICU barriers and facilitators. We sought aframework that would account for the complexity of thisenvironment and identified the integrated PromotingAction on Research Implementation in Health Services(i-PARIHS) framework [17]. This framework and theparent Promoting Action on Research Implementationin Health Services (PARIHS) acknowledge complexity ofimplementation in actual practice. PARIHS is a widelyused conceptual framework designed to explain orpredict success of implementation [18, 19]. i-PARIHSdiffers from PARIHS in that it incorporates a broaderview of evidence and context, acknowledges the functionrecipients play in implementation success, and placesfurther emphasis on the role of facilitation [17]. In iPAR-IHS, the innovation, recipients, and context exist asconstructs that are modified by facilitation in the processof implementation [17].This qualitative study aimed to address a gap in the lit-

erature around PICU-specific implementation barriersand facilitators using the i-PARIHS framework and putsforth a comprehensive process model to understandchange in the PICU. Rather than focusing on a singleintervention, we broadly explore implementation in thiscomplex system. This approach has the potential to in-form adoption, delivery, and sustainability of differenttypes of evidence-based interventions and translate toimplementation benefits across the PICU population[20]. Additionally, we provide insight into using the rela-tively new i-PARIHS framework and comment on utilityin this clinical setting.

MethodsStudy designSemi-structured qualitative interviews were carried outto prepare for a study that will examine prospectiveimplementation of new blood transfusion recommenda-tions for critically ill children. The interviews aimed tounderstand prior experiences with implementing clinicalpractice changes within the PICU. Ethics approval forthe study was obtained from the Stanford University In-stitutional Review Board (IRB-47140). The completedStandards for Reporting Qualitative Research (SRQR)checklist https://www.equator-network.org/reporting-guidelines/srqr/ is included as additional file 1.

Participants and settingWe conducted interviews with health care providersworking in various roles from eight PICUs across theUSA. We selected units to represent variation in PICUtypes (pediatric ICU (excluding cardiac patients, 4 units),pediatric cardiovascular ICU (CVICU) (2 units), and

Steffen et al. Implementation Science (2021) 16:15 of 15

https://www.equator-network.org/reporting-guidelines/srqr/

https://www.equator-network.org/reporting-guidelines/srqr/

combined pediatric/cardiovascular PICU/CVICU (2units)) and overall PICU size (11-32 beds) in the USA.The three types of ICUs are collectively referred to asPICUs, unless specified. A unit representative helped re-cruit participants. The study team and unit representa-tive sent an initial e-mail to solicit volunteers forparticipation. We provided additional information aboutthe study to respondents and contacted them if theyagreed to participate following review of this informa-tion. We selected participants using a stratified, purpose-ful sampling strategy, as described by Palinkas [21] toachieve a sample of participants within each PICU role.One of two authors (KS and MF) conducted interviewseither in person or via telephone. We obtained theparticipant’s verbal consent prior to each interview. In-terviews were audio recorded and transcribed verbatim.We continued interviewing participants in each roleuntil no new information was forthcoming from newparticipants. The qualitative team members (KS, LH,and GL) held meetings to review data and confirm whenvariation in responses was no longer noted.We developed an interview topic guide from the iPAR-

IHS framework [17]; however, added topics that focusedon barriers and facilitators of clinical practice changesand blood transfusion in the intensive care unit toensure we addressed aspects of change that are not ex-plicit in the iPARIHS framework (Additional file 2). Par-ticipants were asked first to describe a clinical practicechange that had been implemented in their ICU as astarting point to discuss the process and impact of theseinitiatives. Additional questioning focused on exploringPICU culture, receptivity to clinical practice change, ini-tiating and sustaining practice changes, and experiencesand perspectives on blood transfusion in the PICU.Qualitative data related to blood transfusion is notreported in this manuscript.

Qualitative analysisWe used a Framework Approach [22] for qualitativeanalysis with the NVivo (Version 12) software package.Framework is an approach to analysis in which case-level data (rows) are summarized along thematic cat-egories (columns) in a matrix and involves five steps offamiliarization, identifying a thematic framework, index-ing, charting, and mapping and interpretation [23]. Thecoding framework was structured around the iPARIHSconstructs (innovation (the evidence-based intervention),recipients, context, and facilitation) with associatedsubconstructs [17]. We applied iPARIHS in this specificsetting to gain insight into the combination of factorsrequired for successful implementation in this clinicalcare environment [20] and move toward precisionimplementation to ultimately better specify and tailorimplementation strategies [24]. Subconstruct definitions

were not available to standardize analysis; therefore, wedeveloped a codebook (Additional file 3) to define subcon-struct items using definitions drawn from the revised PARIHS framework [25], the Consolidated Framework for Im-plementation Research [26], and the Theoretical DomainsFramework [27]. The facilitation construct was codedbroadly to include any data wherein deliberate support orproblem solving was applied to promote implementation.Following coding, review, and organization of data codedwithin the facilitation construct, it became evident that thisdata broadly aligned with the implementation strategies asdescribed in the Expert Recommendations for Implement-ing Change (ERIC) project by Powell et al. [28]; thus, weorganized this data within the ERIC categories. We alsoadded inductive codes while searching for emergentthemes, particularly around implementation barriers andfacilitators to address potential constraints of using theiPARIHS framework to structure our analysis. At the outsetof the analysis, two researchers (KS, LH) selected and codedfived interviews independently using the a priori codes fromiPARIHS, while creating new codes for emergent themes.The researchers met to agree on definitions and interpreta-tions of existing codes, compare coding, and discuss emer-ging themes and integrate into the coding framework. Oneresearcher (KS) coded the remainder of the interviews usingthe established coding strategy. We initially categorizedcoded data within the iPARIHS subconstructs, then, follow-ing the Framework approach, summarized data to retaincontext for ease of comparisons across units and roles.Following summarization, we compared and contrasteddata between roles and clinical units, with careful consider-ation of identifying patterns as well as unique, but inform-ative statements that provided an alternative perspective tocapture variation. Strategies to ensure credibility (internalvalidity) of findings followed guidance by Miles et al. [29]and included linking data to categories in iPARIHS,checking for negative evidence, and checking thatfindings are replicable across the dataset (i.e., acrossmore than one PICU).

ResultsFifty health care providers were interviewed: PICU at-tendings (n = 15), fellow trainees (6), resident trainees(4), nurse practitioners (NPs) or physician assistants (9),nurses (10), and subspecialty physicians/surgeons whosepatients were cared for regularly in a PICU (6), such ashematologists/oncologists, cardiologists, and general andcardiothoracic surgeons. Providers in each role wereinterviewed at each site, with the exception of fellow orresident trainees, as they were not present in some units.Unless specified, the term “providers” refers to these in-dividuals collectively. Interviews lasted a median of 53.5min (range = 37–79 min) and were carried out betweenDecember 2018 and June 2019. Through exploration of


the iPARIHS framework’s innovation, recipient, context,and facilitation constructs, we identified six themes andnine sub-themes that were important for change in thePICU.

The PICU as a high-risk environment for clinical practicechangeWithin the iPARIHS recipients and context subcon-structs, providers identified unique sub-themes of thePICU environment that increased complexity aroundclinical practice change and had important implicationsfor implementation. These include added complexitywith team-based care, high-stakes care that limited re-ceptivity to change, variable readiness for change, limitedbandwidth, and the emotional toll of the PICU environ-ment; each sub-theme is further described in Table 1. Ofnote, receptivity to change related to providers beingamenable to or interested in change conceptually,whereas readiness to change occurred when providershad the appropriate resources (time, skills, support) tooperationalize the change. When providers were receptiveto or ready for a change to occur, change was facilitated.Conversely, when providers were either not receptive to achange or not ready to integrate the change into practice,this served as a barrier to change.

Three sources of changeProviders reported that the stimulus for change in thePICU, located within iPARIHS innovation and contextconstructs, typically originated from three sources: (1)from a motivated individual or group with a specificinterest working within the unit, (2) from a sourceoutside the unit, or (3) as a result of a negative or sub-optimal clinical outcome (iPARIHS Construct: Context;Sub-constructs: Local level Culture, Local level Pastexperience with innovation and change, Organizationallevel Priorities, Organizational level Culture). Based onprior experience or personal interest, individuals orgroups proposed change initiatives to improve care. Out-side sources included the hospital, hospital system, or,infrequently, a regulatory agency; associated changes wereusually intended for the entire hospital or organization.Often, these changes did not account for PICU workflowor unit dynamics and were more difficult for providers toboth accept and integrate into practice (iPARIHS Con-struct: Innovation; Sub-constructs: Degree of fit with exist-ing practice and values). Providers disliked these changes“imposed” on the PICU and preferred when they weremodified to fit PICU practice. Providers of all professionsnoted that changes were made in response to adverse out-comes with significant or unexpected morbidity or mortal-ity (iPARIHS Construct: Context; Sub-constructs: Locallevel Culture, Local level Past experience with innovationand change). In these cases, clinical practices that were felt

to be causal were often modified or abandoned despiteprior demonstration of safety or success as providers werehighly motivated to avoid future negative events: “There’s alot of anecdote as well. Like there was that one bad caseone time, so we don’t ever want to try that again” (Site 1CVICU, Attending 2). Changes made in response to ad-verse outcomes were often made quickly and sometimeswithout obtaining provider input.

Unit leadership and unit-based processes: decision tomake a change guided by leadershipPrior to initiating change, unit leaders made the decisionto devote resources and pursue a change. Identifiedthrough the iPARIHS recipients and context constructs,there was variation in who made the decision to pursuea change in practice. PICU physician and nursing leaderswere often noted to work together to decide on makingchanges; however, in some cases, nursing or physiciansmade decisions independently without input from otherprofessions (iPARIHS Constructs: Recipients, Context;Sub-constructs: Power and authority, Local level Cul-ture). One NP noted: “A lot of policies and changes tonursing care are driven by nursing leadership. The med-ical team leadership is not necessarily involved in thosechanges…[it’s problematic because] we don’t learn aboutnew standards of care until the nurse actually prints outa new copy of it” (Site 1 Combined PICU/CVICU, NP12). Half of units had unit-based committees (multi-pro-fessional or nursing only) that informed leadership’sdecision to make a change. Other professional groups(respiratory therapists, etc.) and subspecialists wereroutinely omitted in many units from the decision tomake a change, though there was a broad understandingthat obtaining feedback, making modifications, andobtaining buy-in from all professions as change movedforward was essential (iPARIHS Construct: Context;Sub-constructs: Local level Culture, Local level Pastexperience with innovation and change).

Individual determinants: multiple determinants impacteda provider’s decision to accept and adopt changeWhile unit leaders made the decision to institute achange in the unit, in many cases, individual providersmade an independent decision to support the change aspart of their practice. While some changes were notedto be mandatory, providers who did not support achange could avoid using it in many cases, as there wasnot direct accountability. The individual provider’s im-pression of a proposed change impacted their willingnessto comply with or resist the change. This impressionwas determined by four sub-themes within differentiPARIHS constructs: (1) the evidence behind the change(iPARIHS Construct: innovation; Sub-constructs: Under-lying knowledge sources), (2) rationale for change (iPARIHS


Table

1Descriptio

nof

sub-them

eswith

exam

ples

iPARIHSco

nstruc

t(s)

iPARIHSsub-con

struct

(s)

Them

eSu

b-the

me

Description

Exam

ple

Recipien

tsCon

text

Collabo

ratio

nand

team

work

Locallevel:

Mechanism

sfor

embe

ddingchange

PICUas

ahigh

-risk

environm

entfor

clinicalpractice

change

(sectio

n3.1)

Com

plexity

with

team

-based

care

Careisprovided

bymulti-profession

alteam

s,each

with

different

know

ledg

eand

expe

rtise.Chang

erequ

iredseekingou

tinpu

t,en

surin

gbu

y-in,

orprovidinginform

ation

toallteams,adding

complexity

“whe

neveryouwantto

actuallyeffect

anykind

ofsign

ificant

change

,the

re’sa

lotof

peop

lewho

have

toge

ton

board.

And

ofcourse,assoon

asyouadd

morecooksin

thekitche

nthings

seem

toslow

down”

(Site

1CVICU,A

tten

ding

1).

Recipien

tsCon

text

Motivation

Locallevel:C

ulture

High-stakes

limit

receptivity

tochange

PICUcare

andde

cision

-makingishigh

-risk,with

potentialfor

sign

ificant

morbidity

ormortality.

Providersde

scrib

eda

desire

toavoidne

gative

outcom

esat

allcosts.

“Our

cultu

reisthat

peop

leliketo

usethesame

protocolsbe

causethey’re

proven

,and

nottryto

change…especiallywhenit

comes

tobabies’health

”(Site

2CV

ICU,surgical

subspecialist

34).

Recipien

tsCon

text

Values

andbe

liefs;

Motivation

Locallevel:C

ulture

Variablereadiness

forchang

eCon

tinuo

uschange

sin

patient

status

andne

edforalteratio

nsin

care

plansmakesome

providersreadyto

change

,and

some

resistantto

it.

“Peo

plewho

workin

ICU

tend

tobe

kind

ofconstantlyreadyfora

change

inpatient

cond

ition

,they

arealso

kind

ofhard

wiredor

prepared

for

changesinotherw

ays”(Site

3PICU

,NP23)

“The

unitisa…veryintense

andchaotic

place.Ithink

we

cravestabilityandsomeof

thestabilityiscentered

arou

ndeasy

decisio

nmaking.”(Site

2Co

mbined

PICU

/CVICU

,Attending

44)

Recipien

tsCon

text

Time,resources,supp

ort

Locallevel:C

ulture

Limited

band

width

Unitsoftenfunctio

ned

atlim

itsof

capacity;

providersfelt

overworked,

repo

rted

units

wereun

derstaffed.

Staffandleadership

turnover

andtempo

rary

staff(i.e.traveling

nurses,residen

ttraine

es)

posedchalleng

esto

consistent

useof

new

practicechange

s.

“Inertia

from

being

overworkedisabarrier[to

change

].Peop

lehave

really

high

clinicalloads,so

they

don’twantto

makea

change

.Ifit'sno

talready

partof

your

habit…

gets

pushed

downthepriorities”

(Site

3PICU

,Fellow22)

Con

text

Locallevel:C

ulture

Emotionaltollo

fthePICU

environm

ent

Emotional,ph

ysicaland

men

talexhaustion

noteddu

eto

unpred

ictableand

difficultcases.Em

otions

“Mostkids

dono

thave

any

oftheproced

ures

orou

tcom

esthat

ourpatients

do.Ithinkthat

definitely

flavorsho

wpe

oplereactto


Table

1Descriptio

nof

sub-them

eswith

exam

ples

(Con

tinued)

iPARIHSco

nstruc

t(s)

iPARIHSsub-con

struct

(s)

Them

eSu

b-the

me

Description

Exam

ple

influen

cedeffortsto

change

practice.

things...Ithink

thestakes

arehigh

erin

manywaysfor

manyof

thethings

that

we

do,orat

leastitfeelsthat

way.”(Site

1Com

bine

dPICU/CVICU,A

tten

ding

9).

Inno

vatio

nUnd

erlyingknow

ledg

esources

Individu

alDeterminants

(sectio

n3.4)

Eviden

cefor

change

Strong

scientific

eviden

ceforchange

was

apo

werfulstim

ulus

toconvince

providersto

change

,particularlyfor

physicians

andNPs.

“For

providers–isit

clinicallyrelevant,d

oesit

provideabe

nefit?How

much?

Wene

edto

see

research.W

ene

edto

see

data

that

show

sthat

thisis

goingto

beworth

the

effort.”(Site

3PICU,N

P24)

Inno

vatio

nRecipien

tsRelativeadvantage

Values

andbe

liefs;

Motivation

Ratio

nalefor

change

Ratio

nale:

Und

erstanding

the

ratio

naleforachange

,go

als,andpo

tential

bene

fitsof

achange

werevitally

impo

rtant

forallp

rovide

rs.

“Som

etim

espe

opledo

n’t

fully

unde

rstand

thereason

fortrying

tomakea

change…

Eitherthatit’sno

trelayedor

explainedinthe

right

manner…

iftherewas

abette

rund

erstanding

they'd

bemorelikelyto

beon

boardwith

it.”(Site

1Co

mbinedPICU

/CVICU

,Attending

11)

Recipien

tsValues

andbe

liefs;

Motivation

Provider

level

factors:provider

expe

rience

App

rehe

nsionarou

ndchange

:Provide

rsno

ted

beingappreh

ensive

abou

tchange

,preferrin

gthe“old

way

todo

things”

“The

hardestthing[abo

utchange

]ispe

oplearejust

soused

todo

ingitacertain

way.Itm

akes

peop

lenervous

tochange

theway

that

they’ve

alwaysdo

nethings.It

may

take

yououto

fyour

comfortzone,and

peop

ledo

n’tlikethat.”(Site

4PICU

,NP35)

Recipien

tsMotivation;skillsand

know

ledg

eDurationof

Expe

rience:

Moresenior

providers

wereofteniden

tifiedas

beingless

receptiveto

change

than

less

senior

providers,ho

wever

theseprovidersalso

influen

cedpracticeand

couldfacilitate

acceptance

ofchange

.

“The

peop

lewho

have

been

here

forthe

long

est,arethe

leastlikelyto

embrace

change…Theearly

adop

ters

aretheyoun

gerp

eople.

Especiallythepeop

lewho

comefro

motherp

lacesand

who

have

seen

itdo

nedifferently.”(Site

1CV

ICU,

Attending

,2)

Recipien

tsValues

andbe

liefs;

Motivation

Provider

level

factors:be

liefs

Perceivedne

ed:C

hang

ewas

perceivedas

“neede

d”if1)

the

“Ithink[thechange

was

easy

because]everyone

was

alittle

bitfrustratedwith

the

lack

ofprocess,or

protocol


Table

1Descriptio

nof

sub-them

eswith

exam

ples

(Con

tinued)

iPARIHSco

nstruc

t(s)

iPARIHSsub-con

struct

(s)

Them

eSu

b-the

me

Description

Exam

ple

existin

gprocesswas

frustratin

g,2)

the

change

preven

tedabad

outcom

e,or

3)it

aligne

dwith

the

provider’spriorities,

hospitalvalues,or

practices

atothe

rcenters(ben

chmarking

).

previously”(Site1PICU

,Attend

ing6)

Recipien

tsValues

andbe

liefs;

Motivation;Skillsand

know

ledg

e

Potentialfor

negative

outcom

e:Providers

worriedchange

smight

have

ane

gativeim

pact

onou

tcom

esandne

wpractices

may

beless

safe

ininexpe

rienced

hand

s.Sign

ificant

shifts

inpracticeweremore

difficultto

accept.

“It’sno

tjustthatwe’re

stuck

inou

rways.Wewantto

dothings

thatweknow

we’re

good

atandthat

are

effective.Even

ifsomething

[new

]might

besligh

tlymore

safe,isitmoresafeinmy

hand

s?I'm

notsure.”(Site

1PICU

Attending

5)

Recipien

tsValues

andbe

liefs

Com

prom

ised

autono

my:Some

providersfeltcreatio

nof

standard

practices

might

comprom

isetheir

autono

my.

“Som

epe

oplefeellike

they’re

gettingtheir

freed

omtakenaw

ay…

they

aren

’tgo

ingto

have

that

creativefre

edom

tochoo

seho

wthey

wantto

manage

apatient...whe

nthey

feel

liketheiroverallautho

rityis

beingtakenaw

ay,it’s

hard

forsomepe

ople”(Site

4PICU,N

P35)

Recipien

tsValues

andbe

liefs;

Motivation

Provider

level

factors:

Perceivedbenefit/

effort

Costvs.b

enefitof

change

:Manychange

srequ

ireadditio

naltim

eor

adding

atask;the

bene

fitof

thechange

mustexceed

the“cost”

ofchanging

,otherwise

itisless

likelyto

beaccepted

orpe

rform

edconsistently.

“The

re’sprob

ablysome

balanceof

howimpo

rtantis

[thechange]?How

easy

isit?

Ifsomething

’sreally

impo

rtant,even

ifit’sreally

difficultto

do,peoplewilldo

it.Ifsomething

’son

lymod

eratelyimpo

rtant

then

youprob

ablyneed

alow

amou

ntof

resistanceto

doit.”(Site

2CV

ICU,Fellow29)

Recipien

tsCon

text

Time,resources,supp

ort

Locallevel:C

ulture

Com

petin

ginterestsandtim

eChang

esthat

were

unrealistic

dueto

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Constructs: innovation, recipients; Sub-constructs; Relativeadvantage, Values and beliefs; Motivation), (3) provider-level factors (iPARIHS Construct: recipients; Sub-constructs: Values and beliefs; Motivation; Skills andknowledge), and (4) competing interests and time (iPAR-IHS Constructs: recipients, context; Sub-constructs: Time,resources, support; Local level Culture) (Table 1). Providerlevel-factors were intrinsic to the individual provider thatinfluenced perception of and receptivity to change. Weidentified three factors within this sub-theme: provider ex-periences, provider beliefs, and balancing benefit with ef-fort. Provider experiences refer to how receptivity tochange and implementation were dependent on a pro-vider’s level of experience or prior experiences working inthe PICU. Provider beliefs were ideas providers held abouttheir own practice or change in the PICU that impactedtheir receptivity to change. Finally, all providers perceivedthat change required an additional investment of time andeffort. Each provider explicitly or implicitly recognizedthat they balanced the “costs” of a change (time, effort)with the perceived benefits of the intervention. Table 1 de-scribes each of these sub-themes and factors in detail andprovides an example of how providers discussed them.

Operationalization of facilitation through implementationstrategiesWe gained perspective on the iPARIHS facilitation con-struct by asking providers about barriers and facilitatorsof change as well as prior experiences with change.Broad coding for this construct yielded a wide range ofdata elements describing actions and strategies used topromote implementation. These data were often linkedwith one or more of the innovation, recipients, and con-text constructs, which made it difficult to characterizeelements within a single iPARIHS construct given theunique PICU context. The actions and strategies thatconstituted facilitation mostly fit within the ERIC cat-egories of planning, restructuring, education, qualitymanagement [30], as detailed in Table 2. These facilita-tion strategies have key features that are unique to thePICU environment which we will describe.Sub-optimal levels of engagement around new evi-

dence and need for practice change (iPARIHS recipients,context) among some providers were an importantbarrier to changing existing clinical practice. This oftenstemmed from professional expectations and require-ments. Nurses were not expected to stay abreast of newevidence which impacted receptivity to change, asdescribed by one nurse: “Not all the nurses have made itpart of their professional practice to stay updated on evi-dence… Practice changes that come from new evidencecan be a little more challenging for that group” (Site 3PICU, Nurse 25). Support given to nurses and othernon-physician providers to spend time working on

practice changes was also limited: “One of the challengesis that they [hospital administration] call our work [onchange] ‘non-productive time’…they don’t allot a lot ofresources to it. Some people are willing to go above andbeyond without getting paid, but it’s not very wellresourced” (Site 3 PICU, Nurse 25). As such, lack of ex-pectations or incentives to work on change in these roleshindered progress.Providers felt identifying a champion within each pro-

fessional role was necessary to ensure a resource existedto support each group (iPARIHS recipients, context).Champions were stated to be knowledgeable about andpromote use of the change, remind and reinforce whychange was being made, and in some cases, assist withimplementation. As in many implementation efforts,achieving buy-in from both leadership and front-linestaff was essential; in addition, for nurses, creating trueownership of change was noted to be particularly power-ful in ensuring consistent application of the change.Informing large and complex PICU teams (iPARIHS

context) of a change was identified as a challenge butwas also noted to be vital to elevate awareness and en-sure that teams worked in concert to use new processes.Multiple modalities of communication (both written andverbal) were needed within multiple settings (meetings,huddles, newsletters, email announcements, computer-based learning modules, etc.) to ensure reach to all pro-viders. Finally, nurses, in particular, preferred advancednotice about upcoming change to allow them to prepareto integrate changes into workflow; they appreciated op-portunities to practice using new skills or techniques ina simulated setting prior to roll-out.Providers emphasized the need to have easy access to

information and tools required for change at all times(iPARIHS innovation, context). Different units had vari-ous established options (electronic, hard copy, signage),but providers differed in their opinions about which ofthese worked best. Because multi-professional educationabout change was often completed at a time remotefrom actual implementation, additional “just-in-time”training at the time of change “roll-out” was viewed asvery helpful, particularly by nurses.Following initial implementation efforts, providers

needed consistent and frequent exposure to a new inter-vention to ensure that it became part of their workflow(iPARIHS innovation). Infrequent opportunities to use achange (i.e., for a rare condition) made it difficult to in-tegrate into practice, as one provider noted: “Sometimeseverybody agrees that there’s going to be a policy changebut it may be six months before you encounter asituation where that change would be implemented andthen nobody remembers.” (Site 2 PICU, medical sub-specialist 18). Any effort to make change automatic orefforts to allow providers to practice using a change to


Table 2 Implementation strategies important for facilitation in the PICU

Strategy Description Example

Plan strategies

Tailor strategies to overcomebarriers and honor preferencesa

Tailor strategies to overcome barriersand honor preferences

“I think engagementc of the bedsideproviders [helps change occur]...really tryingto understand how a change will affect thework and then modify the proposedchange based on the information that youget from people at bedside.” (Site 3 PICU,Attending 21)

Conduct local consensus discussiona Achieving buy-in from leadership andbedside providers, creating ownershiparound change for those who usechange on a daily basis

“Giving more ownership to the bedsidenurses about the changes that areimpacting the practice helps change to bea little bit easier.” (Site 1 Combined PICU/CVICU, Nurse 13)

Identify and prepare championsa Identifying champions from eachdiscipline impacted by change

“Having people who are champions atmultiple different levels of stakeholders…whoever it may be that’s going to beinvolved to really lead that effort helpschange occur” (Site 4 PICU, Attending 36)

Restructure strategies

Change physical structure,equipment, records systemsa

Embedding change into work systems(including EMR)

I think electronic medical record isprobably the one thing that can help a lotwith [implementation] since there is somuch of our work [that’s done there](Site 4 PICU, Fellow 38)

Educate strategies

Conduct educational meetingsa Multi-professional education aroundchange

“I think that there would have to beeducation [for a proposed change]. Andnot just for physicians, but also for nursepractitioners and for bedside nurses tounderstand why and where this is comingfrom” (Site 1 CVICU, Attending 2)

Make training dynamica Creating ways to reliably inform largePICU teams about change (usingmultiple modes of communication)

I think it is helpful doing [education] in amultitude of ways that are kind ofrepeated, to capture as many people aspossible. (Site 4 PICU, Attending 36)

Time-sensitive training Just in time education around the timeof change roll-out

“For nurses, [change is facilitated by] “bootson the ground” things. The huddles, just-in-time education. (, more responsive tothat sort of environment. (Site 2 PICU,Attending 20)

Develop effective educationalmaterialsa

Creating easy access to informationabout change, tools needed

“[a new protocol/process] would need tobe in a place of easy access… in academicinstitutions where you’re having newrotators come through every several weeks,[you need to] make sure that there is away to introduce it to folks” (Site 2Combined PICU/CVICU, Resident 50)

Advance notice about change Giving providers time to preparefor change

“[Change is hard if] it really greatly impactsour workflow and doesn't come with anypreparation…If I know it’s coming, and Ican personally think about how is this isgoing to affect my practice, and how I’mgoing to mitigate that issue (Site 3 PICU,Nurse 25)

Practice using change Repeated use of change to create“muscle memory” around change(infrequently used changes are muchharder to incorporate)b

“It’s repetition [that helps change “stick”].Whether it’s repetition of practice or justrepetition of education …sometimeseverybody agrees that there’s going to bea policy change but it may be six monthsbefore you encounter a situation wherethat change would be implemented andthen nobody remembers” (Site 2 PICU,medical subspecialist 18)


create “muscle memory” around the change were alsovaluable.

Sustainability of change in the PICUFollowing initial implementation, sustainability of changein the PICU was a formidable challenge, but of significantinterest, as maintaining the benefits of successful practicemodifications over time is important. While iPARIHSdoes not address sustainability directly, we inferred identi-fied strategies for sustainability through discussions of theiPARIHS context subconstruct “mechanisms for embed-ding change.” Aspects of planning, including ensuringbuy-in from all professional groups, and promoting as-pects of changes that have direct value for providers, wereidentified as being important for ultimate sustainability.While all provider roles saw great value in tracking andproviding data around the impact of change, physicians in

particular saw great benefit in this method to sustain buy-in and increase compliance. Importantly, many providersnoted that their unit lacked resources to collect and reportdata back to unit staff, representing a major limitation tosustainability, and an opportunity for improvement. Oneattending physician involved in quality improvement com-mented: “There’s certainly great efforts to make more ofour interventions data driven, but that hasn’t been empha-sized as much…So creating that whole infrastructure – it’sa big task” (Site 1 CVICU, Attending 1). Providers also feltthat frequent reminders about the rationale for changeand about the change itself promoted sustainability.

A model for implementing change in the PICUThrough exploration of the iPARIHS framework’s con-structs and identification of the themes described above,we developed a model for change implementation in the

Table 2 Implementation strategies important for facilitation in the PICU (Continued)

Strategy Description Example

Quality management strategies

Develop and organize qualitymonitoring systemsa/Audit andprovide feedbacka

Tracking data/evaluation of the impactof change (monitoring compliance,outcomes, safety data)b

I think reporting back…so that peopleknow, “Hey this thing we started this ninemonths ago?...Here’s what happened. That’sobviously an incentive for people to feellike it made a difference” (Site 2 CVICU,Attending 28)

Remind cliniciansa Frequent reminders about existence,importance of/rationale behind newchangeb

“[change is facilitated by] Informalreminders…the way sometimes people willremind you, “All right, let’s make sure weare doing our check lists at the end ofevery patient,” or the way people say, “let’sremember to wash our hands in and out ofevery room.” (Site 2 CVICU, Fellow 29)

Conduct cyclical small testsof changea

Iterative changes made to enhanceuse of change process

“[to make change “stick”] a check-in and afeedback session would probably be good,and if small changes need to be made towhatever protocol that’s established, theycan be made and re-evaluated.” (Site 2PICU, Attending 17)

Other strategies

Ensuring adequate resources Obtaining adequate resources to plan,implement, and sustain change

“Resources [can be a barrier to change] aswell. Most changes require some sort oftime, effort, if not other financial resourcesto implement.” (Site 4 PICU, Attending 36)

Communicating early success Celebrating “successes” of change “One of the ways that we found [to helpmake change] most successful wascelebrating our successes…we put it in thenewsletter, and celebrated it.” (Site 3 PICU,Nurse 25)

Accountability Creating accountability for change(may be from frontline staff)

“There needed to be more accountabilityfor…how do we make sure these thingsget done? So, they developed this littlelist…you had to sign off, you had to turn itin before you left. That went on for 6months, and then people had kind of builta habit into their practice.” (Site 2Combined PICU/CVICU, Nurse 48)

aDenotes described ERIC strategybNoted to be important for sustainability of changecEngagement in this case denotes the process in which a those planning a change solicit feedback from providers who will use a change toprovide insight into how to optimize implementation


PICU (Fig. 1). This model reflects the iPARIHS con-structs and subconstructs and extends beyond iPARIHSto illustrate the relationships between PICU-specificfactors that influence change, including the hospital andPICU environment that influence change appreciably.These relationships are not reflected in iPARIHS, butlikely crucial to understand when planning implementa-tion in the PICU. As a process model [31], our modeldescribes the manner in which research is translated intopractice within the PICU; this process includes multiplephases.Ideas are initially proposed by individuals or groups

(three sources of change, as described in Section 3.2).The decision to pursue change in the unit is made byunit leadership (unit leadership: Section 3.3). Our inter-views did not explore the factors that influence howleadership selects changes to pursue; however, availableunit resources, unit needs and priorities, and mandatesat the hospital level likely contribute to these decisions.Individual providers also choose to support or resist achange based on multiple factors (individual determi-nants, Section 3.4), including the evidence and rationalefor the change, their own beliefs and experiences, thepotential benefit versus the effort required to change,and time required in light of other competing interests.While initial subthemes such as evidence and rationalefor change are necessary, they are superseded by subse-quent subthemes. As such, regardless of the evidence orrationale for a change, implementation will not occurunless providers perceive that the benefits of a changeexceed the effort required and they have adequate timeto operationalize the change. Change subsequently requires

facilitation (Section 3.5), implementation, and later, effortsto ensure sustainability (Section 3.6).Individual determinants and unit/team processes

interact with one another and influence the selection offacilitation activities which are operationalized primarilyas implementation strategies; likewise, facilitation activitiesimpact these factors and are linked in a bidirectional fash-ion. Facilitation efforts enable implementation; whether ornot a change is implemented is dependent on individualdeterminants and unit leadership and processes. This rela-tionship is unidirectional. Finally, after initial implementa-tion, if a change has been integrated into workflow, it maybe sustained. The PICU environment exerts an influenceon this entire process of change, impacting how individ-uals perceive proposals to change and their ability to inte-grate changes into standard work. To a lesser degree, thehospital may also influence change, often when hospital-wide modifications to practices are also mandated in thePICU. We acknowledge that this model is idealized in thelinear arrangement; in actual practice, implementationsteps are unlikely to be sequential, and implementation ef-forts may stall and require teams to go back to a previousstep before a change is integrated into workflow. Thismodel emphasizes the factors and their relationships thatimpact implementation and may be used for implementa-tion planning in this setting.

DiscussionFrom this qualitative study using the iPARIHS framework,we identified interactions between constructs and shapedthose into a model for change in the PICU, which, to ourknowledge, has not been previously described. Elements

Fig. 1 Model for implementing change in the PICU


missing from the iPARIHS framework, but relevant inother implementation models [32, 33] have been added.Implications for planning implementation in the PICUexist within each model element and phase. The phases ofchange are shaped by the PICU environment, with anessential need to involve members of large, complexmulti-professional teams, and acknowledge the high-risk,high-stakes nature of the work at near capacity, andapprehension about potentially worsening outcomes thatoften makes providers hesitant to improve care that is ad-equate, but could still be improved significantly. Decisionsto change were made both by unit leadership who sup-ported change at the unit level and individual providerswho made an independent decision to support or resistchanges. Some providers readily embraced change, whileothers sought out stability in this unpredictable environ-ment. Notably, providers who were sometimes identifiedas the least likely to embrace change were also most influ-ential in supporting initiatives and critical for ensuringbuy-in and success; specifically involving these providersin change and ensuring their participation may be usefulfor implementation among other staff looking to these in-dividuals for guidance around use of new changes. Sinuffet al. reported barriers and facilitators in relation to guide-line adherence in adult ICUs and identified several find-ings similar to those in the PICU, notably the need foreffective leaders, tailored education based on learningpreferences, reminders, and data-based evaluation [16].While Sinuff et al. stress the importance of creating a cul-ture that supports guideline use [16], this study highlightssome of the barriers in the PICU environment and culturethat can hinder implementation and ultimately are im-portant to address when creating an implementation plan.

Using iPARIHS to understand PICU implementation effortsThe iPARIHS framework was generally helpful as a de-terminant framework in exploring implementation; wefound the innovation, recipients, and context constructsoverall were a useful scaffold to structure thinking aboutimplementation in the PICU. Harvey and Kitson placefacilitation central to the process of implementation iniPARIHS, as it “activates implementation through asses-sing and responding to characteristics of the innovationand recipients within their contextual setting” [17].While the other main iPARIHS constructs are expandedfor users with detailed subconstructs, facilitation is some-what under-defined. The characteristics of a facilitator aredescribed; however, the actions that constitute facilitationare not detailed, and there is no sub-classification of thetypes of activities or strategies that facilitators might utilizeto enable and support change. Lack of clarity around theaction of facilitation constituted somewhat of a “black box”in the framework, despite the fact that it remains crucialfor implementation. We aimed to further describe

facilitation by identifying activities that “activated imple-mentation” through our interviews and subsequent qualita-tive analysis. While this work does not go as far as topropose a comprehensive set of facilitation subconstructs,we provide insight into facilitation activities that may beuseful in the PICU, which are presented in Table 2. Astrength of our work is the delineation of the activities im-portant for facilitation, which in this PICU environmentconsisted primarily of activities that could be linked withknown implementation strategies. By developing a morecomprehensive and clear understanding of the facilitationconstruct, we aim to advance the framework and poten-tially inform future identification of important facilitationsubconstructs within iPARIHS. We offer this critique basedon our qualitative data and suggest that to further improvethe framework, a more detailed description of componentsor features of facilitation would be useful for frameworkoperationalization and in determining where facilitationbarriers exist. Moreover, identifying these activities may bekey to informing the selection of implementation strat-egies, which continues to be an active area of inquirywithin implementation science [34] and holds practicalvalue to those translating evidence into practice.Implementation strategies identified through assess-

ment of facilitation in our work in the PICU have beendescribed by others in similar ICU environments. de Voset al. and Stevens et al. noted the importance of engagedstaff and adequate resources to facilitate change [5, 15];in our study, facilitation of change was impacted by vari-able provider engagement and the time and personnelallocated to work on change. Other authors have reportedthe utility of some of the same facilitators in the ICUenvironment including the need for multiple educationalmodalities and a team of motivated champions [7, 8].The process model that we have put forth organizes

the iPARIHS constructs to reflect how change occurs inthe PICU setting and potentially informs how groupsmight identify barriers and facilitators and plan imple-mentation strategies. We did, however, find there wereiPARIHS subconstructs that were infrequently discussedby providers (i.e., goals, organizational absorptivecapacity) and may not be as important in this setting.We also identified novel concepts not included in theframework and interplay between constructs that hadimportant implications for implementation.Some of the iPARIHS subconstructs were difficult to

separate from one another in the PICU setting. Withinthe recipients construct, motivation and values and beliefswere often inter-related. Within innovation, usability andclarity were related, and within context, we found that dis-cussions of past experiences with innovation and changewere linked closely to mechanisms for embedding change,as many efforts attempted to integrate changes into PICUworkflow. While this did not complicate our analysis, the


fact that these and other sub-constructs often “traveledtogether” or were interlinked should be noted.There were a few frequently discussed concepts that did

not easily fit within any of the iPARIHS subconstructs.These findings may reflect the fact that we created aprocess model from the determinant iPARIHS framework,but could potentially be considered useful additions to theframework. Providers’ emotions were conceptually distinctfrom motivation or values and beliefs and had an import-ant influence on the work environment and the stressorsthat might prevent acceptance of change. Another ex-ample was the importance of having regular opportunitiesto use a change in actual or simulated practice for nurses;however, there was no subconstruct within innovationthat captured this concept. We observed a few instanceswhere factors within one construct significantly influencedanother. For example, the concept of loss of autonomywith standardization of care fit within the construct of theinnovation; however, recipients were also impacted. Inexamples like these, factors influencing implementation inthe PICU did not fit neatly within single iPARIHSconstructs; understanding the links between constructshas implications for implementation planning.The iPARIHS framework lacks formal subconstruct

definitions. Guided by other existing frameworks, wedeveloped more explicit subconstruct definitions thatmay be used in future studies to guide a standardapproach to qualitative analysis using this relatively newframework (Additional file 3). To further build on iPAR-IHS, we posit that standard definitions for subconstructsbe developed to ensure consistent use of terms. This isparticularly important for use of the framework withinthe research setting, as the need for uniform definitionshas been noted frequently in implementation science[35]. We also suggest that further exploration of theconcept of facilitation, with potential for development ofsubconstructs to further define components or actions.This will provide users with context to evaluate andoperationalize plans around this critical element of theframework.

LimitationsAn aim of the larger study was to investigate implemen-tation of blood transfusion recommendations, as such,we enrolled participants who ordered or administeredtransfusions but did not include other providers whomay play a role in implementation of other PICU prac-tice changes (respiratory therapists, pharmacists, pa-tients, etc.). While it was not within the scope of thisproject to include the perspectives of all allied healthprofessionals who work in the PICU, we perceive thatour model of change, which is based on a number ofdifferent pediatric ICU models, is likely fairly compre-hensive, but which may benefit from additional nuance

that the inclusion of these groups might offer in futurestudies. While we aimed to ensure that PICUs were rep-resentative of the scope of US practice, it is possible thatnot all variations in PICU culture are represented andthat the data presented is not fully generalizable to otherPICUs; however, using the iPARIHS framework helpedto ensure that we captured characteristics of the changeprocess that are broadly transferable across settings.Barriers, facilitators, and implementation methods notedby interviewees reflect their opinions; in reality, differentelements of the PICU setting may be more important tooptimize implementation; however, this analysis servesas a starting point for guiding and testing implementa-tion in this setting.

ConclusionsThe PICU environment and providers significantly shapethe nature and process of implementing clinical practicechanges, with need for accommodation of large, complexteams, high stakes work, and individual providers whoapproach change in light of their own experiences,beliefs, and capacity to integrate changes into an alreadydemanding workflow. Unit or hospital-based systemsmay not provide resources to optimize facilitation andparticipation in change and often do not have establishedmethods to provide data on the impact of changes. TheiPARIHS framework was adequate to identify barriers andfacilitators of change in this environment; however, furtherelaboration of subconstructs of facilitation was necessaryto operationalize the framework. Our process model forimplementation in the PICU may guide selection of imple-mentation strategies in similar environments and augmentefforts to integrate change into workflow.

Supplementary InformationThe online version contains supplementary material available at https://doi.org/10.1186/s13012-021-01080-9.

Additional file 1.

Additional file 2.

Additional file 3.

AbbreviationsCVICU: Cardiovascular intensive care unit; PICU: Pediatric intensive care unit;ICU: Intensive care unit; iPARIHS: Integrated Promoting Action on ResearchImplementation in Health Services; NP: Nurse practitioner; PARIHS: PromotingAction on Research Implementation in Health Services

AcknowledgementsNot applicable

Authors’ contributionsKS conceptualized the project with LH, conducted provider interviews,analyzed and interpreted the qualitative data, and was a major contributor inwriting the manuscript. LH also analyzed and interpreted the qualitativeinterviews and assisted in writing and editing the manuscript. MF conductedsome of the provider interviews. GL, SA, and EP provided additional support


https://doi.org/10.1186/s13012-021-01080-9

https://doi.org/10.1186/s13012-021-01080-9

in planning the project, interpreting the data, and in framing and editing themanuscript. The authors read and approved the final manuscript.

Authors’ informationNot applicable

FundingResearch reported in this publication was supported by the National Heart,Lung, and Blood Institute of the National Institutes of Health under AwardNumber K12HL137942. The content is solely the responsibility of the authorsand does not necessarily represent the official view of the National Institutesof Health.

Availability of data and materialsThe datasets used and/or analyzed during the current study are availablefrom the corresponding author on reasonable request.

Ethics approval and consent to participateEthics approval for the study was obtained from the Stanford UniversityInstitutional Review Board (IRB-47140). Per the IRB, the participant’s verbalconsent was obtained prior to each interview.

Consent for publicationIndividuals provided verbal consent prior to participating in interviews. Theverbal consent process included reading the following statement: “Yourinterview will be audio recorded and transcribed for analysis. Study findingswill be presented in aggregate; individuals will not be identified in anypresentations or publications. De-identified quotes may also be used inresearch papers or presentations”. We have presented individual quotes thatindicate the individuals’ role and ICU type only. The selected quotes do notreveal any specific details about the individual that could lead to identificationof the individual.

Competing interestsThe authors declare that they have no competing interests.

Author details1Department of Pediatrics, Division of Pediatric Critical Care Medicine,Stanford University, 770 Welch Road, Suite 435, Palo Alto, CA 94304, USA.2Stanford Division of Primary Care and Population Health, Stanford, CA, USA.3Department of Pediatrics, Division of Pediatric Cardiology, StanfordUniversity, Palo Alto, CA, USA. 4Department of Pediatrics, Division of PediatricInfectious Diseases, Stanford University, Palo Alto, CA, USA. 5VA Center forInnovation to Implementation, Stanford Division of Primary Care andPopulation Health, Palo Alto, CA, USA. 6George Warren Brown School ofSocial Work, Washington University in Saint Louis, Saint Louis, MO, USA.

Received: 10 September 2020 Accepted: 1 January 2021

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