NURS 836 Week 4 Discussion Board Forum 4 on Hybrid Studies and Implementation Outcomes Example

Discussion Board Forum 4: Two Questions in One Project

NURS 836 Translational Research in Health Care, Discussion Board Forum 4

Thread by [Student Name]

The hospital and the classmates replied to are composites written for a model discussion; the textbook and studies cited are real.

Our chief nursing officer asked me a question this week that sums up the chapters. If pressure injuries fall after we introduce prophylactic dressings in long surgeries, how will we know the dressings caused it? And if they do not fall, how will we know whether the dressings failed or we did? The first question is about effectiveness. The second is about implementation. Brownson et al. (2018) treat these as different questions requiring different measures, and the hybrid study exists to answer both at once.

Effectiveness-implementation hybrid studies were introduced in three types: type 1 tests effectiveness while gathering information on implementation, type 2 gives the two equal weight, and type 3 tests implementation strategies while observing clinical outcomes. Ten years later, the original authors recommended speaking of hybrid studies rather than designs, because the essence is combining the two kinds of question in one study, whatever design is used, and they offered questions to help choose a type based on the evidence, the context and stakeholders' concerns (Curran et al., 2022).

For my project, type 2 fits. The evidence that silicone foam prevents pressure injuries is strong, but most trials were outside operating rooms, and nobody has trialed our exact protocol, which dresses sacrum and heels ahead of positioning for every case booked at three hours or longer. We therefore need to know whether injuries fall here, and equally whether staff apply the dressings correctly and consistently. A type 1 study would underweight the rollout, and a type 3 study would assume an effect we have not yet seen in our own operating rooms, so the middle path matches what we actually do not know.

Clinical outcomes alone cannot answer the second question. Proctor et al. (2011) proposed eight implementation outcomes that sit apart from clinical results, among them how acceptable and appropriate a practice seems to staff, how widely it is adopted and how deeply it penetrates, how faithfully it is delivered, what it costs to implement and whether it is sustained. I will measure four. Acceptability will be assessed with a brief survey of circulating nurses and surgeons at month two. Adoption will be the proportion of surgical services using the dressings by month three. Fidelity will be checked by auditing ten cases a week for correct placement on sacrum and both heels before positioning. Penetration will be the share of eligible surgeries in which the dressing was applied. If injuries do not fall but fidelity is 40%, the dressing has not failed; the rollout has.

Reply to Kendra

Kendra, you chose a type 2 hybrid for your early warning score project, but the practice you describe has been implemented in hundreds of hospitals with consistent results. That may point toward type 3. Curran et al. (2022) suggest that when the evidence for an intervention is strong and the main uncertainty is how to implement it in a new setting, a study that focuses on implementation strategies while still observing clinical outcomes is appropriate. Brownson et al. (2018) make a similar point about matching the study's emphasis to what is unknown. Your real question seems to be whether your rapid response nurses will respond to the score, which is an implementation question. What would change in your plan if the primary outcome were response time rather than mortality?

Reply to Andre

Andre, your list of implementation outcomes for the sepsis bundle was thorough, but it left out implementation cost, which your leaders will ask about first. Proctor et al. (2011) include implementation cost as a distinct outcome, separate from the cost of the intervention itself: the staff time, training and monitoring needed to put a practice into use. RE-AIM's twenty-year review also emphasizes reporting costs and resources so that others can judge whether a program is feasible for them (Glasgow et al., 2019). For a sepsis bundle, the cost of the nurse educator's time and the daily audit may exceed the cost of the supplies. Could you estimate those hours from your pilot unit?

References

Brownson, R. C., Colditz, G. A., & Proctor, E. K. (Eds.). (2018). Dissemination and implementation research in health: Translating science to practice (2nd ed.). Oxford University Press.

Curran, G. M., Landes, S. J., McBain, S. A., Pyne, J. M., Smith, J. D., Fernandez, M. E., Chambers, D. A., & Mittman, B. S. (2022). Reflections on 10 years of effectiveness-implementation hybrid studies. Frontiers in Health Services, 2, Article 1053496. https://doi.org/10.3389/frhs.2022.1053496

Glasgow, R. E., Harden, S. M., Gaglio, B., Rabin, B., Smith, M. L., Porter, G. C., Ory, M. G., & Estabrooks, P. A. (2019). RE-AIM planning and evaluation framework: Adapting to new science and practice with a 20-year review. Frontiers in Public Health, 7, Article 64. https://doi.org/10.3389/fpubh.2019.00064

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76. https://doi.org/10.1007/s10488-010-0319-7