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