Table 1 Facilitators of use of the NIRN Model

The NIRN Model is effective and gives credibility to implementation of best-practices

“The NIRN Model has a strong practical element… it’s a very powerful framework.” (2016-10-24)

“The utility is fantastic. What I found of value is just knowing that it is there.” (2016-10-24)

“It’s a structure to be followed to ensure practice implementation, things are done appropriately. [We] have been talking about that in the past three years; we felt we weren’t being taken seriously. Now all of the sudden we are.” (2016-09-12)

“[NIRN gave the language, credibility to speak about and frame implementation]. We all know in a practical sense that it is going to work. When you have a framework, people take things more seriously. Administrators in the group appreciated and understood that there was some research around the NIRN Model and that there was an actual tool we were following that could capture where the holes were. It really supports the work.” (2016-09-12)

“It facilitates adoption and practice change, and if you do it well, fidelity to the practice.” (2016-10-24)

The NIRN Model, AIFs and DMCA processes align well

“[The NIRN Model] offers something familiar, and aligns with and makes explicit what people already do.” (2016-10-24)

“When I look at the DCMA Model and what the NIRN components suggest, both align very well from what I am seeing so far. Haven’t seen anything in the NIRN that hasn’t been introduced or utilized as people have been implementing decision-making capacity assessment processes.” (2016-10-24)

“I think the NIRN Model has a lot of use for the DMCA pre-assessment because it is such a complex process that we are using. To have something as detailed and that allows you to explore all the different components of it made a lot of sense in my mind… I think it fits really well with this go around trying to implement this DMCA pre-assessment process.” (2016-10-24)

“It’s a good match, but only if you have someone guiding the process.” (2016-10-24)

The NIRN Model provides a clear process for implementing DMCAs

“The NIRN Model facilitates a more global approach to implementing something so that you have a greater chance of it being permanently adopted and having that sustained change.” (2016-10-24)

“The NIRN Model has an enormous amount of detail to it, but it does provide excellent framework for figuring out where to go next.” (2016-09-26)

“Reflecting on items in the NIRN Model allowed me to distill where things are going well and where things aren’t and look at foundational things that may have been overlooked otherwise… It helped guide how to present things, influence corporate office around policy, support all these different sites, determine who needs to be involved, how to disseminate information and go from there." (2016-09-12)

"There is a lot of content, but as you are working your way through, it cues you to think about aspects that you might not have in place, to consider where are we… I like how it keeps re-cueing you to think, “did you look at that”, “do you have a plan written out”, “how are you going to coach that”, “did the plan go out”, [I] see some great value there.” (2016-08-15)

“It allowed me to see how the organization I worked for had implemented things. [If you] had not gone through a process like this and then you wonder why certain initiatives don’t work and others do… it gives a very structured path and allows you to go back into it and double check: has anything been missed, are there areas that needs to be revisited and those are the things I really liked about it.” (2016-09-26)

“For the process itself, I think the way it is set out and the way it is displayed—how it follows the steps, it’s just set up really clearly and I think that is what I wanted to see. There is a structure to it and there is a way to follow through.” (2016-09-26)

“It makes things explicit and everyone is on the same page.” (2016-06-20)

Usable innovation: the NIRN Model and AIFs challenge professionals to define DMCA best-practices

“We are currently… trying to gain consistency with our terminology… I think all of us working through the process also helps confirm that at this level, we all have similar sort of ideas about what should be and what we think should be happening. I think our gold standard of what the practice is would be identified as quite similar. [The challenge is to] come up with something that is concise and using terminology that is consistent.” (2016-09-12)

“The Practice Profile Activity really helped to describe the gold standard of DMC processes, what was acceptable and unacceptable.” (2016-10-24)

“Fidelity Assessments support determination of whether decision-making capacity assessments are being done well.” (2016-09-26)

“Fidelity indicators help to really look at what will indicate what is actually happening.” (2016-09-26)

Stages of implementation and the analysis tool enables systematic evaluation of activities and the development of an action plan to improve the success of ongoing implementation efforts

“It looks very comprehensive.” (2016-08-15)

“A lot of information in terms of utility. It systematically encourages one to look at the different stages… useful.” (2016-08-15)

“[The tool] systematically encourages one to look at the different stages… useful to think about where we are with the DMCA…gives you a sense of where you are at in the process which is useful because sometimes these things feels very complex. [Stages of Implementation Analysis] can be used as a tool to keep one on track—especially in initial implementation, when it is a new thing and it keeps everyone on the same page.” (2016-08-15)

“I like how it is broken down with the different levels—exploration, installation, initial implementation, full implementation.” (2016-08-15)

“The advantage of using a system like this—you can be at different stages even within the stages, different places: i.e. initiating things, thinking ahead and planning.” (2016-08-15)

“When we look at how we implement [the DMCA process]…, we did a number of processes without following a specific model which I think was good. But what this does is that it keeps you more accountable. We have some practices and processes that weren’t as effective—could have revisited and been more objective: how can we strengthen this, what do we need to do differently, what can we do next? [We] could use a process like this to go back and revisit that.” (2016-08-15)

“I like [the headings]: in place, not in place, partially in place, seems like clear questions… if you went through it, you would come up with some specific conclusion, build on your plan, and specific action items that would need to be put in place that might be overlooked otherwise to hinder successful adoption.”

“When looking at difficulties—why is the implementation not working, why is it not sustainable, where are the things breaking down, how do we make it sustainable, I realize in looking at the tool—it’s about the detail of it that is significant—many of the things we can put that is not so specific to the site I do feel that in getting into such detail, it might be the key to determine what is working and what is not.” (2016-08-15)

Exploration: enables thorough assessment of site readiness prior to implementation

“I like how the hexagon tool pieces together all the things we need to look at and consider before we actually truly implement…it helps to sets out what exactly it is that we will need to figured out, talk about, can use to actually engage the SW, OT, other stakeholders in it in terms of the need, fit, evidence… bringing it more down to the tangible what we can do.” (2016-08-15)

Installation: ensures that appropriate components (e.g., education, organizational structures, buy-in, champions, implementation team, a communication plan) are in place so as to facilitate successful implementation

“Having people who are engaged and passionate about the topic who are willing to take on the load [made implementing the practice possible].” (2016-11-25)

“We are going to implement the policy anyways, so it will be in place.” (2016-11-25)

“I think the most important thing that has happened is education…” “The training went well. The implementation of the training afterwards not so much, because we are not doing this everyday so it is going to be a process and take longer to get everyone up to speed.” (2016-11-25)

“Having meetings scheduled made implementation possible”. (2016-11-25)

“Buy in from managers and administrators.” (2016-11-25)

Implementation of best-practices is a process

“I’m just happy that were actually putting best-practices into place.” (2016-11-25)

Making the process explicit is helpful

“It is interesting to see at an organization level how it has been implemented, so how that background work gets done as well and how person-centred care has been at the forefront. That’s really what the DMCA model has been, so it’s been really good to see how that has unfolded over the last couple of months.” (2016-11-25)

Learning strategies (e.g., use of huddles and worksheets) are supportive of implementating the DMCA best-practice

“We attached huddles to the IP rounds because we didn’t want to add another meeting.” (2016-11-25)

“If you didn’t have the huddles… it would’ve been effective. You needed the huddle to get a picture of what the individual was. It helped with educating.”The huddles made people see that there was something… happening. And for the problem solving piece too.” (2016-11-25)

“The huddles really help work through problems. Worksheets are a nice guide for huddles, really helps drive our huddles”. (2016-11-25)

“I really liked the worksheet. It really helped guide and outline the process and as far as education goes, I think it is one of those things that you do enough of it then you learn how to do it.” (2016-11-25)

Mentorship and consultants are essential during implementation

“We always had someone to go to or a resource when they were stumped.” (2016-11-25)

Implementation teams are critical to ensuring all aspects of implementation

“When I looked at our initial group as we embark on this project, we were all involved—a lot of us are front line staff who want to make a moral and ethical change. We looked at educating our peers and being an example and model, resource to them. But we didn’t have authority to look at things like performance—providing feedback to upper level of the organization, to have other key changes take place….Things are able to be picked up within various part of the organization from front line staff and some things are reserved for senior leaders.” (2016-08-15)

Implementation drivers facilitate operationalization of the best-practice

“The drivers piece is very important and a good reminder for us of all the various pieces that have to be in place in order to get this to work.” (2016-08-02)

“The thing I like about the NIRN is identifying different drivers and the processes together, we came up with a number of concrete action plans that we can do to move forward. So there is an overall feeling of positivity that we are identifying goal along the way that we are achieving but also realize that there are very significant issues that need to tackle as they are starting to come up…” (2016-09-26)

 Leadership drivers

“Leadership at all levels but also in parallel lines.” (2016-08-02)

“Site leaders that are actually engaged and attached to the mentoring team.” (2016-11-25)

“[Having] the right people… at the table almost starting into the initial stages of implementation…getting the people at the table that is actually part of what we have in our drivers. We acted on those right away and brought those people to the table. It changes the dynamic and makes the process richer.” (2016-09-26)

 Competency drivers

“Is it necessary to have a champion? I would say unequivocally yes. Would it be helpful to teach others what it means? Yes, if we were trying to learn from scratch, it would be the blind leading the blind… Experiential knowledge—it was key she had been through it with other groups before so she can give you that soft knowledge.” (2016-10-24)

“For some of these changes that take place, there is a time component where people have to set time aside to do training and to have the system support.” (2016-08-02)

“Coaching and training plan were really good. They make it very overt who is going to do what—very clear.” (2016-09-26)

 Organizational drivers

“Time… to sit down with people who are clinician and those who have the senior leader’s eye to facilitate practice change.” (2016-09-12)

“Dedicated human resources makes implementation possible. For example, one facility has a .8 FTE for one year to focus on capacity assessment implementation and sustainability.” (2016-10-24)

Documentation: “The structured note: it is key to success. It’s a collective space where people can go and input data, make it more real, as opposed to places where there is no system in place.” (2016-08-02)

Improvement cycles

support adaptation of processes to ensure success

“You have to go back part way and then move forward—so we have been engaging in that cycle… carry forward what you have already, but add pieces that you need.” (2016-09-26)

Evaluation: the NIRN framework provides measurable components and helps service providers identify organizational gaps and barriers to the uptake of the best-practice

“What I like is that it’s broken down into measurable components.” (2016-06-20)

“I like how it’s broken down with the different levels—exploration, installation… It cues you as you work through to think about aspects that you might not have/have put in place… consider where are we.” (2016-08-15)

“It’s helpful that there’s a framework to use to ask: who, what, where, when, how, why. When applied to CHOICE day program, seniors clinic, long-term care, that is where we found that as we were working through [the NIRN framework], we found the gaps quite clearly…as a result, they helped guide how we present and influence our umbrella, organization, our corporate office around policy, how to support all these different sites, who needs to be involved, how to disseminate information and go from there.” (2016-09-12)

“Probably having tick marks as a starting point is a good start… Percentage is difficult evaluate—what does 60 versus 80% mean?” (2016-08-15)

“One of the nice things of a tracking tool is that it keeps the momentum going.” (2016-08-15)

Communication: NIRN helps to facilitate communication during implementation

“Adds clarity regarding the individual responsible and who is the next step to assign accountability.” (2016-08-15)