Table 4 Results in terms of linked interventions, underlying theories and responsibilities based on implementation criteria according to CFIR domains/constructs
CFIR Domain | CFIR Construct | Implementation strategy criteria (points to consider based on focus groups) | Intervention (based on focus groups and literature [39, 40, 43, 44, 60,61,62]) | Responsibility | |
|---|---|---|---|---|---|
Intervention characteristics | Evidence Strength & Quality | Starting implementation with pilot institutions. Adducing ICF-Dietetics field studies and other examples (e.g. nursing language). | Conduct a Pilot study | Research Institution | |
Relative Advantage | Conveying the benefits of ICF-Dietetics. | Provide information: on the ICF-Dietetics its advantages and disadvantages adapted to different learning styles | Cognitive theory on learning | Association of Dietitians | |
(disadvantage) | Considering the drawbacks of using the ICF in form of a professional-specific terminology. Avoiding over-categorizing. | Provide information for other professional groups Refine application concept to improve attractiveness | Theory on organizational learning, Theory on learning | Implementation leader1 Developer of the concept2 | |
(advantage and disadvantage) | To consider if the ICF model should be introduced in education and practice. | Refine application concept to improve attractiveness | Theory on learning | Developer of the concept | |
Adaptability | The application concept and the ICF-Dietetics (granularity) have to be adaptable to different settings and workflows in professional practice. In principle, the ICF / ICF-Dietetics offers this possibility. | Provide information: on the possibility for adaptability to different settings adapted to different learning styles Enable self-regulation to adapt application to individual needs | Cognitive theory on learning Behavior, observational learning | Association of Dietitians Developer of the concept | |
Trialability | Providing examples for practice purposes before implementation. | Start with practical-related interactive workshops before implementation | Social cognitive theory | Association of Dietitians | |
Complexity | Being aware of barriers of complexity. It takes extensive experience regarding the assignment to appropriate ICF-Dietetics categories, the use of qualifiers, as well as the assignment to environmental factors and personal factors. | Start with practical-related interactive workshops before implementation Provide training to change group processes | Social cognitive theory Theory on team effectiveness, group decisions | Association of Dietitians (ICF trainers) Implementation leader | |
Provide skills training and feedback on performance | Cognitive theory on learning | Implementation leader | |||
Enable self-regulation to adapt application to individual needs | Behavior, observational learning | Developer of the concept | |||
Putting codes in the background. | Refine application concept to improve attractiveness | Theory on learning | Developer of the concept | ||
Recognizing the large number of ICF-Dietetics categories as a major barrier. Being aware of the need to develop a nutrition and dietetics-related Core Set. | Refine application concept to improve attractiveness: Develop a nutrition and dietetics-related Core Set | Theory on learning | Developer of the concept or Researcher | ||
Being aware of the barrier of initial effort. | Define individual goals for change | Motivational theories | Implementation leader | ||
Taking into account and communicate the need of additional time especially, at the beginning. | Provide training to change group processes | Theory on team effectiveness, group decisions | Implementation leader | ||
Perceived incompleteness of the ICF-Dietetics categories may come through lack of practice and experience in the use of the new language. | Involve opinion leaders or professional peers (educational outreach) | Theories of planned behavior and social comparison | Implementation leader | ||
Design Quality & Packaging | There is a need for an intelligent search function, and the integration of the ICF-Dietetics in electronic health record systems. | Incorporate the ICF-Dietetics into existing information systems for coding purposes | Theory on organizational learning | Implementation leader or institution leadership | |
The application concept has to be well designed and clear. Clarifying questions, such as; what should be documented? What should be done with the documentation? | Refine application concept to improve attractiveness | Theory on learning | Developer of the concept | ||
Beginning with a small Core Set, that should be extensible. | Refine application concept to improve attractiveness: develop a nutrition and dietetics-related Core Set | Theory on learning | Developer of the concept | ||
Beginning with a simplified application. | Refine application concept to improve attractiveness | Theory on learning | Developer of the concept | ||
There is a need for a table of contents. | Refine application concept to improve attractiveness | Theory on learning | Developer of the concept | ||
There is a need for a revision of the ICF-Dietetics (in cooperation with the proprietors of the original ICF-Dietetics). | Refine application concept to improve attractiveness: Revise the ICF-Dietetics | Theory on learning | Developer of the concept | ||
There is a need for a balance between completeness and not confusing. | Refine application concept to improve attractiveness: Revise the ICF-Dietetics | Theory on learning | Developer of the concept | ||
Outer setting | Needs & Resources of Those Served by the Organization | Focusing on patient orientation and patient goals and continuing of care. Recognizing that the focus only on interventions goals, that has set by health professionals could be a great barrier in terms of patient-centered care. | Take care of patient focused goals and satisfaction | Theory on quality management | Dietitians |
Peer Pressure | Conveying the awareness of the necessity to ensure evidence in the future. | Provide general information: to ensure evidence | Cognitive theory on learning | Association of Dietitians | |
External Policy & Incentives | The implementation of the ICF-Dietetics nation-wide should be supported by politics and legal regulation. | Influence decision makers, build political support | Theory on agenda building | Association of Dietitians | |
Presentation of the concept at congresses and other health care events. | Influence decision makers, build stakeholder support | Theory on agenda building | Association of Dietitians | ||
The recently started realization of Primary Health Care Centers could be facilitate the implementation of a multidisciplinary applicable terminology. | Influence decision makers, build public support | Theory on agenda building | Association of Dietitians | ||
Publishing best practice examples. | Provide information of best practice examples | Cognitive theory on learning | Association of Dietitians | ||
Inner setting | Networks & Communications | Integrating and inform other health care professional and aiming a common solution. | Make better use of information technology Provide information for other professional groups | Theory on organizational learning Theory on integrated care | Implementation leader or institution leadership |
Tension for Change | Necessity for implementation have to come from leadership of institutions. | Provide specific information on the advantages of the ICF-Dietetics for managers and the leadership of the institution | Theories on persuasion and leadership | Implementation leader | |
Tension for change has to be seen and build up within the professional group. | Implement continuous improvement activities | Theories on quality management | Implementation leader or institution leadership | ||
Compatibility | ICF-Dietetics needs to be adapted to the dietetic care process, not the other way around. The ICF is not an assessment, but for developing assessments for functioning. | Implement continuous improvement activities | Theories on quality management | Implementation leader or institution leadership | |
Create teams/collaborative for improvement | Theories on quality management | Implementation leader or institution leadership | |||
Recruit and train leaders to integrate or establish a continuous improvement program in dietetics care | Theories on quality management | Implementation leader or institution leadership | |||
Enable self-regulation to adapt application to individual needs | Behavior, observational learning | Developer of the concept | |||
Relative Priority | Conducting needs assessment before implementation, e.g., about the perceived importance of implementing a standardized terminology in dietetics. | Not necessary: evaluations have already been conducted | |||
Organizational Incentives & Rewards | There should be a defined compensation of the additional required time and the recognition from the leadership of the institutions. | Define compensation of the additional required time and the recognition from the leadership of the institutions | Reimbursement theories | Implementation leader or institution leadership | |
Leadership Engagement | Management and leadership of institutions (e.g. the quality assurance departments) have to take responsibility for the implementation. | Provide specific information on the advantages of the ICF-Dietetics for managers and the leadership of the institution | Theories on persuasion and leadership | Implementation leader | |
Available Resources | Resources, especially time and/or additional human resources, have to be clarified in advance. | Provide information about additional resources and clarify them in advance | Theories of Leadership | Implementation leader | |
Characteristics of individual | Knowledge & Beliefs about the Innovation | Conveying clear usability of the application concept and the ICF-Dietetics, e.g. how it works and which steps and ICF-Dietetics categories should be documented. | Provide general information Involve opinion leaders or professional peers (educational outreach) | Cognitive theory on learning Motivational theories | Association of Dietitians Implementation leader |
Conveying the usability of the ICF-Dietetics within a multiprofessional approach, and conveying that not everything is new, but has already been applied in dietetic practice. | Provide general information Involve opinion leaders or professional peers (educational outreach) | Cognitive theory on learning Motivational theories | Association of Dietitians Implementation leader | ||
Other Personal Attributes | Motivating dietitians in order to prevent resistance, e.g. motivate them to overcome the first needed effort for a higher aim. | Define individual goals for change | Motivational theories | Implementation leader | |
Process of implementation | Planning | Evaluate what is taught at universities regarding standardized terminologies in general and about the ICF in particular. | Not necessary: all program directors of universities participated in the focus groups | ||
Planning the implementation stepwise (e.g., firstly, standardizing the assessments and the dietetics diagnosis, then adopting intervention goals with pre-defined goal lists in terms of ICF-Dietetics categories). | Apply intervention stepwise according to the “stage” of change | Stages-of-Change Theories | Dietitians | ||
Standardizing the dietetic care process that is taught in universities. | Standardize teaching plans of dietetics universities | Theory on learning | Directors of universities | ||
Further validation of the ICF-Dietetics should be done in the ongoing process. | Refine application concept to improve attractiveness: Revise the ICF-Dietetics | Theory on learning | Dietitians and developer of the concept | ||
Engaging | Offering of trainings and ICF workshops for practicing dietitians, supervisors for interns and teachers. | Start with practical-related interactive workshops before implementation Provide continuous trainings | Social cognitive theory Theory of Total Quality Management | Association of Dietitians Implementation leader | |
Developing practice-oriented standardized training material. | Provide printed educational material, e.g. a manual of the dietetics care process and the use of the ICF-Dietetics | Theory on learning | Association of Dietitians | ||
Opinion Leaders | Institutions need a person as an opinion leader. | Involve opinion leaders or professional peers (educational outreach) | Theories of planned behavior and social comparison | Implementation leader | |
(Key Stakeholders) 3 | Addressing different settings and work experience of dietitians, such as, students, freelancers and employees, those they just finished their education and those who have been in practice for many years. | Provide information on the ICF-Dietetics for adaptability to different settings adapt to different learning styles | Cognitive theory on learning | Association of Dietitians |