Table 2.

CFIR Inner Setting Constructs, Contextualized Definitions, and Illustrative Quotes

ConstructContextualized DefinitionExample Quotes From Focus Groups
Facilitators of ChangeBarriers to Change
Structural characteristicsExisting clinicians - generational differences in communication and teamwork styles“In general, everyone does have the desire to get along and some of the older generation doctors still live in the world of they’re the boss and ‘don’t tell me what to do.’ But the majority of the appreciate the collaboration and have that understanding that there’s multiple checkpoints along a patient’s care path, and that anyone can catch those.”
“A lot of these new physicians coming in listen to the nurses now. They have a better relationship. They know that the nurses are the ones at the bedside… it’s not so much, ‘I’m the doctor. You’re going to do everything that I’m telling you to do.’ There is a different culture with physicians coming out of med school now.”
“Some of the older doctors that were kind of set in their ways, we still have two of them that just will not change no matter what we do. We’re just waiting for them to retire…because it’s hard to change a culture when you have somebody who’s been doing something for like 25 years and refuses to change, if they have a large portion of the deliveries.”
Size of the organization or hospital unit and how this impacts perceived organizational characteristics and impacts outcomes“With the doctors too...we know each other very well, especially because we have such a small number of physicians working here.”“We have certain doctors … their episiotomy rate is so high that it drags [the quality metrics down] – it’s a small hospital.… They’ll do maybe 20, 30 deliveries a month, but they do episiotomies on half of them so that bumps your epis rate. So individual practices like that, especially in a small hospital that doesn’t [have a large] deliver(y) [volume], has a huge impact on your numbers.”
The current provider mix of L&D providers“we’re in a pretty good place… [because we have been] adding in midwives as the first call for low risk patients. And so the nurses…find that so helpful that they’ve got a midwife to work alongside.”Quantitative/LCS Insight: Increasing the presence of midwives on L&D was seen as a good way to reduce cesarean by only 24% of physicians at non-responder hospitals versus 45% at successful hospitals.
The existence or lack of formalized communication processes and hierarchies; and the functional role of informal communication processes“I would say when we were really doing [Formal Team Training Program], one of the things was after every single delivery, good, bad or otherwise, we did a debrief. And one of the things I liked about that was we didn’t wait for bad outcomes to do debriefs.”
“…It’s often centered around some discrepancy in management, where I want the nurse to do something and she says, ‘I can’t. That’s not protocol or that’s not policy,’… instead of...discarding that…[we] dive into why nurses continue to follow certain policies...It’s just a larger discussion.”
“It can be awkward. Oftentimes, if a nurse is having trouble with a provider or with another nursing staff member, they’ll talk to the charge nurse...The first thing I’ll say is, well have you talked to the person? So sometimes it gets difficult because people don’t want to hold each other accountable...or they feel it’s not their job to do it.…You can’t always just escalate every problem to [Nurse Manager].”
CultureNorms and values of unit, subcultures of nurses and physicians and professional siloes; Cultural flexibility“Well I would say we’re a huge team, and we treat each other like family, and that includes the physicians too that work with us. As far as patients, I feel like we try to provide holistic patient care, including patients, their family members, friends.”
“When we’re making the assignment, we take different things into consideration...if there’s someone who has a natural approach… well so and so’s going to be great for this patient because that’s… how she likes to practice… the nurse then feels rewarded because they’re having the type of experience…that is in alignment with their beliefs as well.”
“One of the things we’ve been able to overcome, the nurses’ story “we’re the patient advocate,” somehow pinning the physician as not the patient advocate. I don’t hear that as much anymore. It’s been better recognized that all of us are patient advocates, but the nurses are still on a 12-hour shift and they’re going to check out in 12 hours and many of us [physicians] will still continue on for days with a patient, if that’s how long it takes.”
Implementation climateFear and resistance to change“Just making it more obvious that there are more people reaching out and trying to address this problem and it’s not going to go away. To me, the bottom line is the physicians. The physicians are the ones who make the call to do the C-section, nobody else. So it’s bottom line, you’ve got to get the physicians more on board with everything.”“Liability is a major player when it comes to physicians and NTSV rates. I think the physicians are scared to take risks and not go to C-section because they’re worried about the liability.”
“I think… fear of a bad outcome, fear of sitting on a strip too long and fear of getting sued. But even more so is fear of having to tell the mom, ‘Your baby has a lot of problems because, you know, we waited too long [to call for a cesarean]’.”
Organizational incentives & rewards“Evidence based process and allow you to do audits and all staff [were] audited. Amazing opinions on how do things better. Did all units and started working. Put up reward boards, celebration,..., personal notes and acknowledgement in huddles. Now they are working on communication. Next collaboration and teamwork. Staffing last per their assessment.”“And those individuals that lack some motivation or lack the understanding of, the importance of some of this stuff and working with them individually... If I were to talk about something right now to help improve, it would be recognizing people for doing a great job and getting that out there.”
Goals & feedback“A lot of it is during our meetings. We have separate meetings regarding the C-section rate, and sometimes we may outline certain problem physicians or certain physicians who are a little bit more quick in making decisions. So some of those physicians have to be spoken to individually and to encourage them to do what they can to be a little bit more conservative.”
Learning climateTeam members feel safe, input is/isn’t valued“The nurses are very strong and they’re solid in their skills, their knowledge in Labor & Delivery. And so I think that gives them more confidence with the physicians and with the providers. And at the same time, the providers then trust them when they are asking them for something or if they’re needing support on something, the doctors are receiving that pretty well because of the trust that they have with their knowledge.”“Some of our charge nurses can be a little bit hard on newer people...When someone’s more of a slow learner or a slower learning curve, there’s sometimes not much patience for that. I think we could do better.”
Leadership engagementLeadership commitment, involvement, and accountability“Well, I just think that working together for so many years, building that trust. I know we have a … our chief medical officer is not an obstetrician, but he’s doing everything he can to learn about obstetrics. So he really drives that from the doctor’s side of it. He is really instilling in the doctors the importance of collaborating as a team. Not that they needed it too much, but he just really reinforces it.”“With [Nurse Manager] being the director when she’s telling people to please do something, it really is more likely to be done than if I was to ask them to do something...[Nurse Manager] is stretched very thin. She has a lot of responsibilities around the hospital and I think maybe it wasn’t totally on her radar so much either, even though we had talked about it. But then when it came down to it, it wasn’t. And with [Physician] being our physician champion, it wasn’t on her radar so much either, even though we had talked about it.”
Readiness for implementationLevel of resources dedicated to implementation and operations; Ease of access to shared resources“We did a lot of joint education, which was great. We did some fetal monitoring education with the providers and the nurses. We’ve been doing simulations. That’s been great with pulling the providers in. We conducted a retreat, a unit retreat about a year ago.”“The physicians themselves too, we don’t have a laborist program, so the doctors aren’t in-house. So knowing that these other providers have 30-minute response times, sometimes the doctors will decide to do a C-section a little bit sooner than maybe they would in another department when they know that they have everyone readily a Category 2 strip they might wait a little bit longer at another facility because they have resources readily available, but because we don’t have those resources always readily available sometimes the doctors will make the decision to do a C-section a little bit earlier than they may have at a different facility.”
  • C-section = cesarean section; CFIR = Consolidated Framework for Implementation Research; L&D = labor and delivery; LCS = Labor Culture Survey; NTCV = nulliparous, term, singleton, vertex.