Table 1 A summary or readiness to implement and corresponding ratings for the strength of each construct and sub-element of PARIHS
PARIHS construct: evidence | ||
Sub-element | Data/results from focus groups and interviews | Strength [20] |
Research | • Many valued that practice recommendations were based on a systematic review published in a well-respected journal • Staff valued literature as relevant but not the only thing to consider, also valuing other ‘evidence’ sub elements • Some staff place high value on the ‘pathway’ as best practice, the value in their use for setting standards in practice, and the general value of early intervention • Some staff concerned about the quality of literature on which the recommendations were based and the reliability of assessments | High High-quality research is valued by staff as one important aspect of implementing change but not the only aspect Some staff are actively and critically engaged with the literature |
Clinical experience | • Many staff are concerned about potential equity issues if the pathway is not able to be implemented across all regions • Staff query the need for early diagnosis in NZ given symptom-based treatment rather than diagnosis-based treatment • Mixed consensus on the research evidence that underlies the need for the early diagnosis pathway in terms of evidence for early intervention and therefore the ‘need’ for early diagnosis. Staff are concerned about providing the label of CP so early, given the ‘baggage’ associated with the label. A label of ‘at risk’ or another term may be preferable • Concern that ‘other’ conditions may be overlooked if the focus is on CP • Clinicians across disciplines see benefit from providing consistent assessments with clear criteria and outcomes • Clinical experience values professionals providing consistent information to parents | Mixed Staff see benefit of providing consistent assessments and information to families but feel uncomfortable with giving CP diagnosis at 3 months Good consensus within allied health although they state that regionally there is no consensus No currently consensus amongst doctors around need/importance of early diagnosis of CP |
Family experience | • Taboo label of CP, with low knowledge about CP for most families • Staff concerned pathway (i.e. MRI, GMA, discussion about CP) might further increase anxiety in NICU families • Staff would like to know the effects of pathway on families who do not go on to have CP diagnosis • Staff value how this pathway would impact families who come to have a CP diagnosis • Current system does not have a clear pathway and can lead to mistrust in health services if families feel a diagnosis has been kept from them | Mixed High: family experience valued as evidence, family integrated care model values partnership with families, family viewpoint highly relevant Low: families not involved in this study |
Local data | • Only a small proportion of (NZ) infants meeting criteria for assessment pathway develop CP • Lack of data collection of CP diagnosis by hospital • Current service needs based not diagnosis based • Staff noticing more conversations about the brain and long-term developmental outcomes | Lack of systematic methods for collection and analysis of local data |
PARiHS construct: context | ||
Resources | • Lack of resources both staffing and systems (e.g. MRI availability, IT systems, clinic times, waiting lists) • Low FTE for allied health • This study seen as an opportunity to potentially bring resources • Skilled and motivated staff, including staff being trained in GMA | Low Current resources perceived to be inadequate (i.e. staffing, systems, MRI availability) |
Culture | • Low awareness of the pathway, especially amongst nurses • Need to improve communication between professional groups • Staff value improving equity in healthcare and are concerned guideline could inadvertently increase inequity • Currently the allied health role is positioned as a ‘visitor’ to the NICU • Desire to provide gold standard care, if it meets the needs of our population • Mutual respect and collegiality between professions | Mixed Low: low awareness of early diagnosis of CP amongst inpatient staff Culture has not had the chance to embrace/reject due to lack of awareness High: enthusiasm for providing neuroprotective care, understanding GMA and HINE could be complementary Staff value providing equitable healthcare |
Leadership | • NICU leaders unwilling to support if resources are not in place • Many competing priorities • Leaders willing to engage and find out more • Nursing leadership have established staff education pathways and ways of capturing time use • Support from nurse educators for access to knowledge and training • Leaders from different professional groups have great respect for each other • Staff unsure/disagreed that the wider organisation supported innovation and innovative people | Low Leadership support is currently low—primarily due to limited resources NICU leaders open to implementation if financial and staffing resources can be sustainably provided across inpatient and community. Leadership would like more information on the cultural fit of the pathway and are concerned for possible equity issues |
Evaluation | • Staff very interested in how families will find this process • Some existing evaluation already in place; however, rate of CP diagnosis is not captured by hospital system • Systems already in place to capture inpatient nursing time use and could capture any increase in workload • Meaningful qualitative evaluations with families are very labour intensive | Low CP diagnosis not centrally reported by hospital staff Meaningful qualitative research on family experience is resource intensive The voluntary NZ CP Register will allow future evaluation (albeit with a time lag) |