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Table 3 Implementation theory domains and sub-categories [10] with quotations

From: Implementation of an older person’s nurse practitioner in rural aged care in Victoria, Australia: a qualitative study

Domains Subcategories Perceived barriers (exemplifying negative quotations) Perceived enablers (exemplifying positive quotations)
Capability The capability of agents to operationalise a complex intervention depends on its workability and integration within a social system. Workability: the social practices that agents perform when they operationalise a complex intervention within a social system, and characterises interactions between users and components of a complex intervention. Integration: the linkages that agents make between the social practices of a complex intervention and elements of the social system in which it is located, and characterises interactions between the context of use and components of a complex intervention. “I mean obviously to try and get the GPs to work collaboratively was probably the biggest hurdle and it is still the biggest hurdle” [staff member] “We are not aware of [OPNP] scope of practice in the first place, that’s our trouble” [focus group participant] “… .it wasn’t implemented well and that may be why we had a lot of issues at the start, because we did not really understand it …” [staff member] “It was hard to know what your position was … an understanding of what your roles will be” [staff member] “Whether the particular need [for an OPNP] was identified I have no idea …” [staff member] “… given that we are a smaller health service here and the GPs are on site, we have that ability to actually get that partnership and that collaboration working really well” [staff member]
Capacity The incorporation of a complex intervention within a social system depends on agents’ capacity to cooperate and coordinate their actions. Social norms: institutionally sanctioned rules that give structure to meanings and relations within a social system, and that govern agents’ membership, behaviour and rewards within it. They frame rules of membership and participation in a complex intervention. Social roles: socially patterned identities that are assumed by agents within a social system, and that frame interactions and modes of behaviour. They define expectations of participants in a complex intervention. Material resources: symbolic and actual currencies, artefacts, physical systems, environments that reside within in a social system and that are institutionally sanctioned, distributed and allocated to agents. They frame participants’ access to those material resources needed to operationalise the complex intervention. Cognitive resources: personal and interpersonal sensations and knowledge, information and evidence, real and virtual objects that reside in a social system and that are institutionally sanctioned, distributed and allocated to agents. They frame participants’ access to knowledge and information needed to operationalise the complex intervention. “… I do not know whether it’s [OPNP role] accepted, or does not have its rightful place in the structure of health care” [staff member] “I think it deskills some of our nursing staff because they seem to think they cannot do anything now without getting a nurse practitioner involved” [GP] “… there is still times when one of the GPs in particular feels that potentially the nurse practitioners might be overstepping the mark” [focus group member] “… they are [GPs] trying to micromanage [OPNP] and I think that’s not allowing [OPNP] to practice to [OPNP] full capacity” [staff member] “The funding models are not there” [staff member] “So funding in certain places has been difficult to get. One aged care facility said ‘well we cannot afford this anymore’” [GP group member] “Having to find additional funds to support [OPNP] is a big issue … it’s going to be very much influenced by what we can afford to do …” [staff member] “… the residents already have practitioners who are quite involved in their care so I think that perhaps for this area it [OPNP] might be a trifle superfluous” [GP group member] “As the GPs have understood – learnt and understood more about nurse practitioner roles they have become more comfortable with letting go” [focus group member] “[OPNP] is also a good resource person …. [OPNP] is a very good link to all those other services” [focus group member] “… employing a nurse practitioner here was predominantly to fill [delay in treatment] gap … prevent them going to hospital unnecessarily …” [staff member] “That makes it quite – I mean, or job, quite a bit easier” [GP group member] “… having a nurse practitioner brings an additional level of knowledge into the organisation …” [staff member]
Potential The translation of capacity into collective action depends on agents’ potential to enact the complex intervention. Individual intentions: agents’ readiness to translate individual beliefs and attitudes into behaviours that are congruent, or not congruent, with system norms and roles. They frame individual motivation to participate in a complex intervention. Shared commitments: agents’ readiness to translate shared beliefs and attitudes into behaviours that are congruent, or not congruent, with system norms and roles. They frame shared commitment of participation in a complex intervention. “I have no reason to dislike [OPNP] … but I do not feel any connection to go and ask for help or seek [OPNP] opinion” [staff member] “It has not been embraced from either side probably as well as what it could have been” [staff member] “The good communication between bodies, staff and [OPNP] or [OPNP] is part of the staff anyway, so it’s reciprocated, that respect” [focus group member] “Everything [OPNP] does he involves people” [staff member]
Contribution The implementation of a complex intervention depends on agents’ continuous contributions that carry forward in time and space. Coherence or sense-making: agents attribute meaning to a complex intervention and make sense of its possibilities within their field of agency. They frame how participants make sense of, and specify their involvement in a complex intervention. Cognitive participation: agents legitimise and enrol themselves and others into a complex intervention. They frame how participants become members of a specific community of practice. Collective action: agents mobilise skills and resources and enact a complex intervention. They frame how participants realise and perform the intervention in practice. Reflexive monitoring: agents assemble and appraise information about the effects of a complex intervention within their field of agency, and utilise that knowledge to reconfigure social relations and action. They frame how participants collect and utilise information about the effects of the intervention.   “Families are certainly very, very keen on it [OPNP]” [staff member] “… we were auditing … I could see the team involvement in the care of residents, especially in their end state of care with the doctors and the GP and the nurse practitioner being involved” [staff member] “You can actually see the results in the clinical indicators … huge improvement … because you are getting better intervention much earlier” [focus group member] “We are reducing [accident and emergency presentations] here because we have [OPNP] on site” [staff member]