Table 3 Contextual factors influencing nudge implementation and key recommendations, by CFIR domain
Contextual factors | Recommendations based on interviews, process documents, and research team experiences |
|---|---|
Innovation Domain | |
❖ Design of the method of intervention delivery (Innovation Design; Innovation Adaptability; Innovation Relative Advantage) | ❖ Evaluate whether email would afford the same advantages (e.g., it involved fewer programming requirements than EHR nudge, could be more easily changed/updated, and required no additional clicks or stops in the EHR) |
❖ Evaluation the validity of the comparator(s) (Innovation Design; Innovation Evidence Base) | ❖ Consider using both guidelines and peer comparison; clearly define “peers” for recipients; provide information on source and evidence base of the guidelines |
❖ Adjustment of the structure and layout of nudges (Innovation Design) | ❖ Put relevant information (e.g., recommended prescribing ranges) toward top of email; include links to guideline evidence base |
Outer Setting Domain | |
❖ Determine external policies and laws impacting opioid prescribing and their specific requirements | ❖ Clarify any discrepancies between legal prescribing requirements and nudge-recommended prescribing quantities |
Inner Setting Domain | |
❖ Assessment of information technology infrastructure (a subconstruct of Structural Characteristics) | ❖ Ensure data and analytics capabilities. Available data and analytics team allowed for successful implementation, but still required up-front and ongoing programming support and personnel time and involvement |
❖ Evaluation of departmental size and culture (Relational Connections; Communications; Learning-Centeredness, a subconstruct of Culture ) | ❖ Discern whether departmental size could change the effect. In this case, departmental size did not correlate with discussions or coordination on opioid prescribing |
❖ Determination of centralization within the Inner Setting (Relational Connections; Communications) | ❖ Effort required to engage leaders at each site over large geographic area; alignment of intervention with site-specific workflows (e.g., pre-programmed quantities in EHR) |
Individuals Domain | |
❖ Engage local champions (High-level Leaders; Mid-level Leaders; Opinion Leaders; Implementation Leads) | ❖ Investigate relevance to nudge recipients of who signs/sends emails; involve local champions to lend support to intervention at department level; use local champions to identify local/department-level variations to consider |
❖ Respond to surgeons’ professional role (Motivation, part of the Characteristics subdomain) | ❖ Recognize the surgeon’s ethical commitment to their patients and desire to “do no harm” |
Implementation Process Domain | |
❖ Receipt and review of nudges by recipients (Tailoring Strategies) | ❖ Use “preferred” email address when clinicians may have looser affiliation with the healthcare setting; use a system to track open rates of emails; consider levels of email fatigue |
❖Assess[ment of] needs and context of recipients during pre-implementation phase | ❖ Recognize and address recipient’s priorities and preferences for pre-intervention education; distribute guideline ranges; provide avenue for surgeons to access additional information (i.e., when questioning patient or procedure information in nudge) |
❖Adapt[ation] the nudge to prescribing workflows | ❖ Attribute prescribing to individual writing prescriptions/discharging patient |