Step 4. Selection and development of strategies
This step involves selecting and developing appropriate strategies based on the most relevant determinants of change for each setting, because priorities may differ from one setting to another.41There is no consensus around methods to use when designing implementation strategies with stakeholders.41Consequently, we developed a method to involve stakeholders based on our research team’s experience in working with stakeholders when implementing change (CH, PR) and expertise in pedagogy (EE).
From May to June 2019, we organized an initial meeting with local working groups in each FMG to validate results, to discuss the local problem, the strategies that professionals wanted to address and their willingness to implement a change, specifically with respect to the role of primary care nurse. Meetings were 90 minutes long and were audio-recorded to allow the researcher to keep track of relevant information as needed. A member of the research team also took notes.
First, schemas of current collaborative practices was presented to each working group for validation and modifications were suggested in each setting. This step helped to update our understanding of current practices in each FMG to take into account any clinical changes that occured since the end of the data collection period. Groups were invited to identify where they thought their practice might be improved using the schema of the process of collaborative care according to CCM evidence. Specifically, they identified on the schema where they believe nurses are actually involved and where involvement may vary among nurses or is infrequent. This was a way for each group to reflect on their practice as well as to validate our results. Moreover, this activity helped update the schema on CCM evidence. According to primary care providers, medical leave was also an important component of the treatment plan for people with CMDs and LTCs.
Following this activity, we presented the problems and strategies prioritized by the Advisory Committee and asked members of the working group if they were relevant to them, if they wanted to work on them and if yes, in what way. Each group was concerned about the identified problems and interested in the strategies, but they selected strategies specific to their context and to the professionals’ willingness to change. Finally, a summary of the meeting including the main problems, strategies and objectives discussed during the first meeting was sent to each member of the group.
The format and number of subsequent meetings/discussions to develop strategies and to begin reflecting on the implementation plan differed between FMGs. For instance, in one FMG we met twice with one nurse to develop the strategy to be implemented. E-mail was also used as a method to communicate with each other. In another setting, we planned a second meeting with members of the working group to further develop and prioritize selected strategies from the previous meeting. Our research team also met with a nurse manager at the regional hospital centre to discuss the feasibility of implementing one of the selected strategies as we needed resources and authorization from the employer. Developing strategies also included a review by the research team of existing materials/resources specific to each strategy. Finally, the research team remained available to assist each FMG in pursuing the change of practice, but the implementation and assessment of strategies were not part of the research project as we were mainly interested in the planning process.
Discussion on lessons learned. This step of the process was relevant to validate results, specifically to confirm processes of care as well as the barriers to changing practice in each FMG. Moreover, predominant determinants of change for each setting arose through discussions with primary care providers involved in the working groups. Previous steps of the process (i.e., step 2 and 3), provided a list of determinants to change collaborative practice in each FMG. However, it appears that those determinants were not necessarily specific to professional activities. To help researchers anticipate a broader range of potential barriers, it might be interesting to collect data during the pre-implementation period on the team’s readiness to implement change with a validated tool such as the Organizational Readiness for Knowledge Translation questionnaire.42
Our experience demonstrates the importance of involving as many clinicians and managers as possible when selecting strategies for change to facilitate the decision-making process and the involvement of the entire team in the change of practice. We also learned that we can’t plan the procedure of each meeting in advance when developing strategies as this depends on too many factors that are not under the research team’s control and also depends on the characteristics of selected strategies. Primary care providers are busy with their own work and responsibilities and research is not always their priority.43 Consequently, the methods we used to reach or involve primary care providers must be flexible and respectful of their workload.
We did not test the effectiveness of our process to plan change, but we encourage other researchers to do so when implementing evidence-based practice. This will contribute to advancing knowledge on how to strategically implement a sustainable change of practice in health care organizations. In general, there is still little knowledge on the effectiveness of using this kind of approach to select implementation strategies tailored to local needs against the more passive dissemination of an evidence-based practice.44