Implementation processes and capacity-building needs in Ontario maternal-newborn care hospital settings: a cross-sectional survey

Although often a healthy event, childbirth is the most frequent reason for hospitalization in Canada and the United States [1, 2]. Given the risk for negative short- and long-term consequences for both the pregnant or birthing person and their infant(s), ensuring that high quality and evidence-based care is provided is essential. Improving maternal-newborn care¹ has therefore become an international priority and there has been a growing focus on the implementation of quality care in these settings [3]. However, evidence-practice gaps remain. For instance, compared to evidence-informed recommendations, there continues to be overuse of practices such as caesarean births, inductions, and formula supplementation [4], among others. This overuse may further strain limited financial and human resources, lead to patient dissatisfaction, and cause physical, psychological, and social harm [5, 6].

Closing these evidence-practice gaps requires evidence-based implementation [7]. Implementation science aims to develop and test methods and strategies to effectively move evidence into practice [8]. Despite a growing body of literature, implementation science has not been well translated into practice-based settings [9]. This has created a “secondary gap” where healthcare teams can identify the need to implement evidence into practice to improve care and outcomes, but they do not necessarily use evidence to inform the processes they use to implement that evidence into practice [10]. However, there are a growing number of examples of teams successfully applying implementation science informed approaches in maternal-newborn care [11‐13] and other settings [14], illustrating the potential of implementation science in improving care processes and outcomes in healthcare settings.

Nurses are frequently tasked with leading and supporting change initiatives, and there are increasing calls for nursing to embrace and apply implementation science in their practice to further improve evidence-based practice [10, 15]. Yet many healthcare providers, including nurses, are not aware of or confident using current evidence on how to implement evidence-based programs, guidelines, or innovations [16]. Nurses and other healthcare professionals are often not exposed to implementation science in their training, and clinical demands, lack of resources and time, and lack of professional development opportunities may preclude them from learning about implementation science and its applications to their work [9, 10, 17].

Given that capacity for implementation (i.e., whether you have enough people with the right skills), has been identified as one of the key factors for implementation success [18], understanding current implementation practice and implementation capacity-building needs in nursing and healthcare settings is critical to inform future interventions and supports. As a first step to explore this, our research team previously conducted a secondary qualitative analysis of 22 interviews with nursing managers and directors in Ontario, Canada [19], and compared their described implementation approach to an implementation science framework [20]. Overall, there was variability in implementation steps taken across hospitals. Several implementation steps were described infrequently or sub-optimally, suggesting that real-world processes were not as comprehensive as the implementation framework used for comparison [19]. However, limitations of the secondary analysis were the inability to assess the implementation process at a more detailed activity level, and the lack of information about healthcare providers’ perceptions of the importance or value of different steps and their confidence completing them. To build on this work, we sought to collect more comprehensive and recent primary data from a broader range of Ontario maternal-newborn nurses, other healthcare professionals, and leaders.

We used the Checklist for Reporting Of Survey Studies (CROSS) to guide the writing of this manuscript [24] (see Additional file 1 for completed checklist).

Between September 20, 2023 and November 22, 2023, 73 individuals completed the questionnaire. Figure 1 presents a flow diagram of the number of responses received and those that were included in this analysis. We obtained a response rate of 26% (73/278). Across the 73 respondents, there was at least one response from nearly two-thirds of Ontario maternal-newborn hospitals (57/91, 63% of maternal-newborn hospitals). There were 13 hospitals that had a response from more than one person; we included these records as the individuals represented different units and/or different professional roles.

In this study we aimed to explore the implementation processes and implementation capacity-building needs of maternal-newborn nurses, other healthcare professionals, and leaders. We grounded our data collection in an implementation planned-action framework, the Implementation Roadmap, to identify how usual implementation practices compare to recommendations from implementation science. We also learned about respondents’ perceptions of importance and confidence completing various implementation activities. Together, this highlights specific phases and activities where maternal-newborn teams may need additional support in the implementation process.

About half of respondents indicated their organization had a mandatory or optional practice change process or framework, and we observed that these respondents more frequently reported always completing activities in the Implementation Roadmap. This is unsurprising given that theories, models, and frameworks encourage a systematic and structured implementation process and creates a shared language and understanding among team members, which may ultimately increase success and sustainability [10, 16, 34]. In addition, some respondents named a formal theory, model, or framework they use. Similar to our previous findings [19], most of these were approaches and tools grounded in quality improvement rather than implementation planned-action frameworks. With the growing recognition that implementation science can inform and improve change initiatives in healthcare settings, it will be important to consider how implementation science and quality improvement practice can work together to achieve optimal processes and outcomes [35].

Respondents identified a variety of roles that are involved in different phases of the implementation process. Nurses in both leadership and clinical roles were the most frequently selected role for leading change initiatives, identifying problems to address, developing solutions, and implementing solutions. These results highlight the substantial and essential role that nurses play in implementing practice changes [15].

We observed that overall, there was strong involvement from nursing managers throughout the implementation process, which is promising given that leadership behaviors of nurse managers affect the unit climate for the implementation of evidence-based practices [36]. However, the involvement of senior leadership was lower, which likely reflects their role in providing general support and infrastructure rather than engaging in the day-to-day activities. Senior nurse leaders have been identified as a key group that can embed implementation science in their organizations [37]. Given our findings that evaluation and sustainability planning and execution were some of the least frequently completed activities, there may be a particularly important role for senior nurse leaders to play in supporting these activities.

We observed that pregnant and birthing people and their families were less frequently involved in the implementation process, a finding consistent with our previous qualitative study [19]. While about half of respondents indicated pregnant and birthing people and their families were involved in identifying problems (likely through patient feedback systems and patient and family advisory committees), there was a notable decrease in the number of respondents who said they also involved them in developing and implementing solutions. This may be a missed opportunity given that involving patients in co-designing solutions can result in improvements to care, service delivery, and governance [38].

Overall, we found that most respondents perceived the three phases and 28 implementation activities to be important, aligning with our previous work in a different setting [39]. Despite these generally positive ratings of importance, we observed that these implementation activities were not always done. There are several potential explanations for the discrepancy between viewing an activity as important but not doing it. Implementation is complex and there are multi-level barriers to implementing evidence in practice [40]. Implementation is often done with limited time and resources in conditions that are rapidly changing, resistant to change, and subject to policies and regulations [41], and this may account for some implementation activities not being feasible to complete, despite being viewed as important. It is also possible that the difference relates to a lack of knowledge and skill in how to complete the activity. This is consistent with respondents most frequently indicating they were “somewhat” confident across the implementation activities, suggesting that room for improvement exists. Given that healthcare professionals are typically not taught about implementation and improvement practice in their training, nor are there sufficient professional development opportunities in this area [9, 42], it is unsurprising that nurses and other healthcare professionals are reported to have low knowledge [43] and skill proficiency in quality improvement [44] and low confidence in knowledge translation and implementation [45, 46].

We observed a general decrease in respondents’ ratings of importance, completion, and confidence when moving across the three implementation phases. Variability in practitioner perceptions across the implementation process has been reported in previous studies [45‐48]. For instance, allied health professionals reported higher confidence levels in the earlier steps of the implementation process (e.g., identifying an evidence-practice gap, finding and appraising evidence), and reported lower confidence levels with activities later in the process (e.g., implementation, monitoring, evaluation) [45, 46]. McNett et al. [48] described three core implementation stages (initiating, maintaining, completing and sustaining) and found that respondents reported moderate difficulty completing each of the stages, with the difficulty ratings increasing across stages. Similarly, respondents rated their success higher in the first phase, with success ratings decreasing in stages 2 and 3. This aligns with our findings that respondents’ ratings of importance, completion, and confidence were highest in the first phase, and decreased in later phases, and signals that nurses, other healthcare professionals, and leaders may need additional support in later implementation activities.

Most respondents identified a need to increase their knowledge and skills in using an evidence-informed approach to implementing practice changes. Our study and previous literature [45, 46] suggest that nurses and other healthcare professionals are in fact interested in learning more about how to implement evidence into practice. Respondents who had previous training in implementation, quality improvement, or knowledge translation rated their knowledge and confidence more positively than those with no training. Implementation capacity-building interventions may result in positive outcomes including increased knowledge and understanding of implementation and an increase in self-reported ability to implement [49]. While we acknowledge that training and tools alone would be insufficient, it is promising to see there is an appetite for further learning about how to effectively move evidence into practice. Ongoing work is needed to develop and evaluate evidence-informed tools, resources, and training initiatives to support the application of implementation science in clinical and health services settings.

While respondents generally viewed implementation activities as important, teams did not always complete the steps or feel confident doing them, particularly in later phases of the implementation process. These findings support the need and interest for further resources, support, and training in using an evidence-informed approach to implementation and will inform the development of a tailored resource for nurses, other healthcare professionals, and leaders in maternal-newborn care settings. Until health systems adopt an evidence-informed process to implement evidence-informed practices, patients will continue to be denied optimal care, resources will be wasted, and equitable health outcomes will be challenging to achieve.