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Abstract

Background:

The dissemination and adoption of research into clinical practice in health care settings is a complex and challenging process. Clinical champions have been increasingly used in health care to facilitate the implementation and adoption of evidence-based practice and to overcome organizational barriers. In relation to substance use and mental health disorders, translation of new evidence into practice is an ongoing challenge. The utilization of a clinical champion to motivate staff to implement evidence-based practice in these settings may improve treatment quality and reduce the burden of disease. We thus aimed to conduct a systematic review to examine the role and efficacy of clinical champions in the drug and alcohol and mental health settings.

Methods:

We conducted a systematic literature search (1980-present) using the following databases: PubMed and PsycINFO. Additional studies were identified using reference searches of relevant reviews.

Results:

Thirteen separate studies were included in the final review. Clinical champions were typically selected rather than emergent, including clinical staff members engaging in a professional clinical role (e.g., physicians, psychologists, social workers). Training provided for these roles was often not stated. Clinical champions assisted with faster initiation and persistence in the application of novel interventions, facilitating overcoming system barriers, and enhanced staff engagement and motivation.

Conclusions:

In the substance use and mental health field, clinical champions appear to be an important component to facilitating practice changes. Future studies should provide specific details regarding attributes and training and also examine the relevant combination of personal characteristics and training sufficient to facilitate implementation of evidence-based practice in drug and alcohol and mental health settings.

Plain language abstract

Treatment delivery in drug and alcohol and mental health settings may not always be based on best available evidence. Organizational context and individual factors are important in determining whether new practices will be adopted. Passive approaches such as websites or treatment manuals do not necessarily lead to change in practice. The clinical champion model has been shown to be effective in aiding implementation of evidence-based practice in health care settings. However, there is limited evidence evaluating its use in drug and alcohol and mental health settings. The current review aims to synthesize and evaluate the use of clinical champions in implementation research in drug and alcohol and mental health settings. We found that clinical champions were typically clinical staff members engaging in a professional clinical role. Training provided for these roles was often limited. Clinical champions may assist with faster initiation and persistence in the application of novel interventions, facilitating overcoming system barriers, and enhanced staff engagement and motivation.

Keywords

Clinical champion substance use drug and alcohol treatment community based training

Substance use and mental health disorders are a major public health concern. They are associated with a range of medical and other psychological comorbidities and significant burden of disease (Whiteford et al., 2015). There is evidence for the use of pharmacological and psychological interventions in these clinical populations. However, specific treatments delivered in clinical settings may not always be based on best available evidence (Powell et al., 2014). When evidence-based interventions are applied beyond the context of a research project, difficulties in translation can arise. Behavior change by clinicians in adopting new practices appears to be only weakly related to the strength of the evidence base (Dopson et al., 2002). The adoption of evidence-based practice into clinical practice in health care settings is thus a complex and challenging process (Bauer et al., 2015).

Implementation science has attempted to understand and improve how research findings can be applied into routine practice (Eccles & Mittman, 2006), including in substance use and mental health settings (Louie et al., 2018, 2020). There are many factors that may influence successful implementation of an innovation, as outlined in the Consolidated Framework for Implementation Research (CFIR) (Damschroder & Hagedorn, 2011). Organizational context and individual factors are important in determining whether new practices will be adopted. Potential barriers to adoption include clinician preferences, resistance to change, staff turnover, workload demands, communication issues and ineffective leadership (Dale et al., 2015; Dudgeon et al., 2012). A number of strategies can be used to implement evidence-based practice at an organization level, including staff training. However, “passive” approaches such as websites or treatment manuals have been found to not necessarily lead to change in practice or clinician behavior (Powell et al., 2014).

Clinical champions are increasingly used in health care to facilitate implementation and adoption of evidence-based practice, and to overcome organizational barriers (Miech et al., 2018). A clinical champion is typically defined as an individual within an organization who has a responsibility to advocate for change, motivate others and use their position and expert knowledge to facilitate the adoption of a particular innovation (Cranley et al., 2017). Clinical champions are most often front-line clinicians who can advocate for and influence practice-driven change. They do this by leading by example and being a resource for other staff members. Previous studies have shown that front-line clinicians are an essential influential factor in the implementation of practice change (Byers, 2017). Driving practice change from the front-line may be more effective in creating organizational change as it can diffuse the adoption of an innovation throughout organizations, instead of imposing change from senior management (Byers, 2017).

The clinical champion model has been shown to be effective in aiding implementation of evidence-based practice in health care settings. Examples of where this has occurred include cancer care (Bowman et al., 2015; Dimoska et al., 2012; Dudgeon et al., 2012), medical and nursing best practices (Graham et al., 2002; Rangachari et al., 2015; Schorr et al., 2016; Thomason et al., 2016; T. A. Williams et al., 2013), stroke management (Dale et al., 2015); pain management (Rosenberg et al., 2016; A. M. Williams et al., 2012) and e-health and technology (Knight et al., 2014; Miller et al., 2004). Clinical champions have been identified in the literature as an essential component in facilitating practice changes (Miech et al., 2018).

Despite the increasing number of publications in recent years demonstrating the effectiveness of clinical champions in facilitating practice change in health, there is limited evidence evaluating its use in drug and alcohol and mental health settings. There are particular issues in the drug and alcohol and mental health settings that suggest that implementation in these contexts is unique in comparison to other areas of health care. These clinical settings typically employ staff with diverse training and backgrounds, including recovered service users to those with more professional qualifications including medical, allied health and nursing. Thus, implementation of evidence-based practice can be challenging in this context due to lack of common professional leadership hierarchies and siloed work practices. Furthermore, these settings have traditionally had difficulty implementing and using evidence-based practices (Saunders et al., 2014). Therefore, the nature of the clinical champion role may be different to that required in other areas of health care. For example, given the above, it is possible that effective clinical champions in these settings may not require certain professional clinical backgrounds and may need to be emergent, due to interest, rather than selected by a manager and may require more face-to-face training than what is observed in other settings. The current review thus aims to synthesize and evaluate the use of clinical champions in implementation research in drug and alcohol and mental health settings.

Methods

A comprehensive review of the literature was undertaken to examine the role, responsibilities, characteristics, strategies used, and effectiveness of clinical champions in drug and alcohol and mental health settings. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for systematic reviews (Moher et al., 2009). The systematic review was registered with the international Prospective Register of Systematic reviews (PROSPERO).

Eligibility criteria

Studies were eligible if (1) they were written in English, (2) they were published from 1 January 1980 until January 2020, (3) they used a clinical champion who was a clinician in a clinical setting, and (4) the study took place in a drug and alcohol or mental health (excluding dementia and geriatric cognitive disorders) treatment setting including inpatient, outpatient, community or primary care settings.

Search strategy

We searched PsycINFO via OVID SP and PubMed using the following key search terms: ([ champion] OR (champion) OR (change agent) OR (opinion leader) OR (liaison)) AND (implementation) AND ([ health] OR (drug and alcohol) OR (addiction)). We conducted reference searches of relevant reviews and articles.

Study selection

After duplicates were removed, titles and abstracts were screened, and one author reviewed full text articles for those that potentially met inclusion criteria. If there was any uncertainty around inclusion for review, a second author was included. Any disagreements were adjudicated by a third author (there were nil disagreements). Data for each article that met inclusion criteria were extracted by one author and included in the synthesis.

Data extraction and synthesis

Data extracted included year of publication, study setting and design, treatment or intervention to be implemented, details about the clinical champions (role, responsibilities, selection, training and effectiveness). A synthesis of the data was performed following data extraction.

Results

Study details

See Figure 1 for PRISMA flowchart. The initial database searches yielded 309 results, 275 after duplicates were removed. Six articles were identified through reference lists searches. Following title and abstract screening, 25 full-text articles were screened for potential inclusion (the remaining articles were primarily excluded due to no use of a clinical champion, or no use of intervention in drug and alcohol or mental health). Eight articles were excluded after full text screening due to insufficient information about clinical champions (Chang et al., 2013; Cohen et al., 2013; Kathol et al., 2010; Sunderji et al., 2019), and use of an intervention not focused on drug and alcohol or mental health treatment (Banks et al., 2014; Bentz et al., 2007; Haynes et al., 2011; Shumway et al., 2018) or in a mental health or drug and alcohol treatment setting (Ballard et al., 2018; Leathers et al., 2016; McCabe et al., 2013). Two selected studies reported on the same trial (Hagedorn et al., 2019; Harris et al., 2017) whereby the Hagedorn et al. study is presented here given that it reported on clinical champions although some information was extracted from Harris et al. Thirteen (13) articles were included in the final synthesis. Papers included in this review were published between 2009 and 2019, with the majority published in the last 5 years. This shows the relative infancy of implementation research on the use of clinical champions in drug and alcohol and mental health settings.

Figure 1.

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram of the study selection process.

Study design

Studies included in the review are depicted in Table 1. The majority of the studies used qualitative or mixed methods while two were quantitative studies. Studies investigated implementation of clinical champions in drug and alcohol services or populations, mental health services or populations, and integrated drug and alcohol and mental health settings. The majority of studies were implemented in the United States of America (n = 9), with the remaining in Australia (n = 1), Canada (n = 2) and the United Kingdom (n = 1). Studies took place across a wide variety of clinical settings including primary care, Veterans Health Administration sites, forensic mental health, inpatient mental health, aged care, community treatment, child welfare agencies and medical residency programs.

Table 1.

Study characteristics and outcomes.

Study	Intervention	Setting	Research design	CC: who were they?	CC: training	CC: role	CC: effectiveness
Hagedorn et al. (2019); Harris et al (2017)	Pharmacological treatment for alcohol use disorder (AUD)	Primary care USA	Qualitative methods (interviews pre-implementation)	– Addiction medicine specialists – Primary care mental health integration champions (clinical pharmacy, social worker or psychologist)	– 1.5 day face-to-face collaborative learning session including education about the intervention as well as skills in facilitating uptake at their sites. – Ongoing monthly teleconferences – Access to library of materials and champion network	– Provide education and support to primary care providers – Provide consultation, educational outreach, information and advice to staff	CC identified as important to implementation. CC time spent on project not related to implementation success. Importance of stability in staff and leadership noted.
Hargraves et al. (2017)	Screening, Brief Intervention and Referral for Treatment (SBIRT) of substance use, depression and anxiety	Primary care USA	Mixed methods: quantitative and qualitative	– Medical director – Program leaders	–	– Problem solving and coordination – Obtaining and monitoring resources – Securing “buy-in” from . . .	CC a facilitator of implementation and sustained use of the intervention
Kipping et al. (2019)	Aggression reduction in forensic mental health facilities (“Safewards” program)	Inpatient mental health facilities Canada	Descriptive and qualitative methods	– Selected by the unit – Interdisciplinary permanent staff members – Likely to be enthusiastic, potential adopters	– Extensive training (5 + days) – Face to face and online – Leadership, implementation strategies – “Co-creations” principles	– Develop implementation strategy – Create intervention materials – Liaise with staff and patients – Consult with other teams and champions	Not directly evaluated. 79% attendance rate at champion training. Collaborative engagement with staff in developing implementation strategy seen as important for engaging clinical staff in the study.
O’Sullivan et al. (2018)	Screening, Brief Intervention and Referral into Treatment (SBIRT) for substance use	Medical residency programs USA	Case study; qualitative methods	– Clinical faculty – Program directors	– Training in the intervention – Library of training materials	– Customize curriculum and draft implementation plan for their specialty – Coordinate educational events	Not directly evaluated. Champions reported that they believed SBIRT was incorporated into clinical practice. Champions noted importance of support from the team, financial support and time to their role.
Cook et al. (2009)	EMDR for the treatment of PTSD	Department of Veterans Affairs Health Clinics USA	Comparative case study; qualitative methods	– Emergent – Senior psychologist	No training	No defined role	Not directly evaluated. The site that adopted the intervention had a CC, whereas the non-adopting site did not
Gordon et al. (2011)	Buprenorphine for opioid dependence	Veterans’ Health Administration sites USA	Qualitative methods	– Emergent – Clinical staff – Often new, proactive staff members	–	– Assist implementation – Changing culture of facility – “Cheerleading” the innovation and justifying the treatment to staff	CC identified as a facilitator of implementation. CC identified as important in overcoming barriers and “status-quo”
Rycroft-Malone et al. (2019)	MBCT Depression relapse prevention (“mind the gaps”)	Mental health services UK	Qualitative, exploratory study	– MBCT teachers, clinicians, service managers – Emergent (self-designated)	–	– Teaching and implementing MBCT – Organize activities – Create formal and informal networks	Champions or “implementers” were identified as key to successful implementation
Pigot et al. (2019)	Stepped care for personality disorder	Mental health services Australia	Qualitative interviews	– Emergent – Clinicians	No specific training	No defined role	CC reported as key facilitators of change and pivotal to implementation
Forchuk et al. (2013)	Transitional Relationship Model (TRM) to enhance continuity of care in psychiatric settings	Psychiatric hospital wards Canada	Qualitative ethnographic study	Clinical staff member	–	– Project leadership – Negotiation (resources, staffing, processes) – Adapt to local organizational demands – Enhance situated learning	Presence of an internal CC identified as a facilitator of implementation, staff considered it to be important. Change in CC became a barrier affecting degree of implementation.
Goren et al. (2016)	Clozapine prescribing for treatment resistant schizophrenia	Veterans Health Administration sites USA	Qualitative	–	–	Not clearly described	Not directly evaluated. Identified as a facilitator of increased clozapine use and lack of champion as a barrier.
Guerrero et al. (2015)	Implementation of co-located mental health and primary care settings	Veterans Health Administration primary care USA	Quantitative (survey)	Primary care clinicians	–	– Championed depression screening and treatment	Not directly evaluated. CC presence (dichotomous variable; presence/absence) not significantly associated with implementation success. Training providers in depression care associated with implementation.
Helseth et al. (2018)	Contingency management for opioid addiction in community based treatment, using Science to Service Laboratory (SSL) implementation strategy	Community treatment clinics for opioid use disorder USA	Quantitative, secondary data analysis	Clinical director	Four day workshop on organizational change and implementation strategies for evidence-based practice	– Staff training – Overcoming organizational barriers – Raising awareness	Not directly evaluated. SSL providers more quickly adopted the intervention, thus champions may assist providers in overcoming barriers to use
Green et al. (2014)	Implementation of buprenorphine treatment for opioid dependence	Two, not-for-profit integrated health plans USA	Qualitative	Clinicians, often a clinical leader	–	– Introduction of treatment to the clinic – Changing clinician, organizational and system characteristics to support use of treatment – Facilitated staff training – Advocate for use of treatment – Planning roll-out	Not directly evaluated. CC considered a facilitator of uptake of the intervention within organizations. Once adopted, clinician experience with, and discussion within organizations of the intervention became more important in sustaining use than CC presence.

CC: clinical champion; AUD: alcohol use disorder; SBIRT: Screening, Brief Intervention and Referral for Treatment; EMDR: eye movement desensitization and reprocessing; PTSD: post traumatic stress disorder; MBCT: mindfulness-based cognitive therapy; TRM: Transitional Relationship Model; SSL: Science to Service Laboratory; –: no information provided.

Outcomes

Who were the clinical champions?

Nearly all of the studies (n = 13) described what types of clinicians were in the role of “clinical champion” for a particular intervention (see Table 1). Champions included drug and alcohol professionals, primary care mental health integration clinicians, senior psychologist or clinical psychologist (Cook et al., 2009; Hagedorn et al., 2019), addiction medicine specialists (Hagedorn et al., 2019), clinical pharmacy specialists (Hagedorn et al., 2019), social worker (Hagedorn et al., 2019), clinicians or managers in the service (Forchuk et al., 2013; Gordon et al., 2011; Green et al., 2014; Guerrero et al., 2015; Kipping et al., 2019; Pigot et al., 2019; Rycroft-Malone et al., 2019). In many cases (n = 5) the clinical champion was someone in a senior position within the service. For example, a team leader (Avalos et al., 2016; Green et al., 2014), senior medical staff specialist (Hagedorn et al., 2019), or a medical or program director (Hargraves et al., 2017; Helseth et al., 2018; O’Sullivan et al., 2018).

Clinical champions were classified as either selected/recruited for the role (n = 8), or emergent or self-designated (n = 4) in the studies that did provide description of the role designation. Only one study did not provide an explanation about who was in this role (Goren et al., 2016). Emergent champions were individuals who emerged as a champion for a particular innovation or intervention due to interest, expertise or passion about the project/intervention/innovation. In one study, emergent champions were typically new staff with fresh perspective/ideas (Gordon et al., 2011). Studies with selected champions included those who primarily had experience in the use of the intervention/innovation. In the study of mindfulness implementation across mental health services (Rycroft-Malone et al., 2019), champions were “passionate” and “willing to go the extra mile” whereby the following characteristics were critical: personal interest and commitment, confidence, passion and dedication with communication skills such as diplomacy and adapting language for different stakeholders.

Champion training

Most of the records (n = 9) did not describe if champions received specific training for this role (see Table 1). Of the records that did provide this information (n = 4), training was provided through face-to-face workshops covering general information about the intervention, organizational change, and implementation and leadership strategies (Hagedorn et al., 2019; Helseth et al., 2018; Kipping et al., 2019; O’Sullivan et al., 2018). In two records, education and training of champions was also facilitated through access to library resources and online training (Kipping et al., 2019; O’Sullivan et al., 2018). In Rycroft-Malone et al. (2019), it was noted that champions developed particular implementation skills yet these were not necessarily developed through specific training but as a result of involvement in the implementation project more generally or skill previously acquired.

Clinical champion role and responsibilities

There was not one particular job description for the role of a clinical champion in the studies examined. On the contrary, multiple roles and responsibilities have been identified as facilitators of practice change implementation in the health care system, with responsibilities varying between different implementation projects. (see Table 1). Of the 13 papers included, 6 provided a clear description of the clinical champion role in their study (Green et al., 2014; Hagedorn et al., 2019; Helseth et al., 2018; Kipping et al., 2019; O’Sullivan et al., 2018; Rycroft-Malone et al., 2019). Of these papers, leadership, provision of education and training to clinicians to enhance skills or knowledge, and acting as a mentor and resource person in their facility, were described as being inherent in the role of a clinical champion (Green et al., 2014; Hagedorn et al., 2019; Helseth et al., 2018; Kipping et al., 2019; O’Sullivan et al., 2018). Other key roles and responsibilities included clinical champions being responsible for creating an implementation plan based on the specific needs and structure of their organizational setting (Green et al., 2014; Kipping et al., 2019; O’Sullivan et al., 2018), or for coordinating and troubleshooting the implementation process (Hargraves et al., 2017). One study used “co-creations” principles where clinical staff and patients were involved in the development and adaptation of the implementation strategy (Kipping et al., 2019). One study additionally included responsibilities such as organizing activities to support implementation and creating informal and formal support networks (Rycroft-Malone et al., 2019).

Effectiveness of champions

Table 1 depicts study information regarding effectiveness of clinical champions. Clinical champions were perceived as playing an important role in facilitating the implementation process in six of the studies (Cook et al., 2009; Gordon et al., 2011; Hargraves et al., 2017; Kipping et al., 2019; Pigot et al., 2019; Rycroft-Malone et al., 2019) whereby some studies specifically demonstrated effectiveness of the clinical champion in contributing to change of practice (Forchuk et al., 2013; Gordon et al., 2011; Hagedorn et al., 2019; Hargraves et al., 2017). One study described champions as being important in the initial adoption of an intervention, and as clinician self-efficacy increased, clinician experiences and that of colleagues became more important to sustained use (Green et al., 2014).

In addition, the importance of stability in the clinical champion role as determining its effectiveness was also observed (Hagedorn et al., 2019). One study found that a change in the clinical champion in the implementation phase became a barrier to adoption, and immediately affected degree of implementation (Forchuk et al., 2013). Furthermore, reliance on few clinical staff members can be a barrier when staff are away or there is turnover (Goren et al., 2016). However, length of time spent in the champion role may not necessarily be associated with implementation success (Hagedorn et al., 2019). Several studies observed that clinical champions assisted faster initiation of and persistence in the use of new interventions, in overcoming systems barriers regarding increasing staff engagement and in developing greater clinician enthusiasm, which may be associated with more persistence in adoption (Forchuk et al., 2013; Gordon et al., 2011; Helseth et al., 2018).

Discussion

This is the first study to conduct a comprehensive review of the role and efficacy of clinical champions in drug and alcohol and mental health settings. Across all studies examined, clinical champions were from varying professional clinical backgrounds including physicians, psychologists and social workers, across a wide variety of clinical settings. These champions were usually selected for the role or they emerged as a champion during implementation due to their interest or experience. Few studies described the degree of training provided for individuals in this role. Some studies provided face-to-face training on intervention information and leadership strategies. Overall, the literature indicates that clinical champions assist in faster initiation and persistence in the application of novel interventions and are central to implementation. They also helped to overcome system barriers, enhance staff engagement and improve staff motivation. Finally, the importance of stability emerged whereby a change to the clinical champion could act as a barrier to implementation.

A major responsibility of clinical champions is to provide education and training to clinicians to enhance their knowledge in a particular area, or to build skills in using a new intervention or tool. Educational opportunities may be implemented formally through the use of structured workshops, clinical supervision, grand rounds or training programs (Green et al., 2014; Hagedorn et al., 2019; Helseth et al., 2018; Kipping et al., 2019; O’Sullivan et al., 2018). Education delivered informally by the presence of champions on site provided a source of information and support when necessary (Cook et al., 2009; Gordon et al., 2011). Clinical champions are typically given the role of being a mentor and resource person in their facility where other staff members can seek their advice and guidance in the specific intervention or tool being implemented.

For studies that provided information about training of clinical champions for their role, the main form of training was face-to-face workshops, where champions learnt about the intervention, implementation strategies, and were granted access to resources and supervision. This type of training may assist champions in understanding their role, equipping them with the skills necessary to perform responsibilities (such as in leadership, communication, negotiation and problem solving) and providing them with a support network. Characteristics that emerged as being critical included having personal interest and commitment, confidence, and good communication skills. Given that the majority of champions in this review were identified as being clinical staff, who may not necessarily hold management or formal leadership positions, formalized training may be important in facilitating effectiveness in their role. One study noted the relevance of a combination of skills and where the champion was placed in their service (Rycroft-Malone et al., 2019). Studies that aim to advance our understanding of what combination of personal characteristics and training are necessary for effective clinical champions specifically in mental health and drug and alcohol settings would be particularly useful.

Consistent with the broader research in health care, champions in drug and alcohol and mental health settings were identified as essential or significant factors in facilitating implementation. However, the unique effects of these champions on implementation have not been examined (Miech et al., 2018). Further research is needed to evaluate the effectiveness of clinical champions on implementation success, and to illustrate core components during implementation. In the wider general health field, positive champion characteristics that have been identified include communication skills (e.g., negotiation, collaboration, advocacy, skilled teacher), enthusiasm and belief in the innovation to drive and implement change, personal qualities (e.g., being personable, respected, credible), leadership skills, and providing feedback to staff (Miech et al., 2018). Indeed, although not examined quantitatively, this appears to be consistent with the current set of studies reviewed in the drug and alcohol and mental health field whereby it appears that these characteristics (e.g. personal interest, good communication skills, interest), may be more relevant than requiring certain professional or formal leadership backgrounds. Typically, in drug and alcohol settings, clinical staff have high workloads (including seeing patients, administrative tasks, meetings) which allow little time to invest in learning new interventions or changing practices. Therefore, these organizational settings may be particularly suited to having a clinical champion who has the interest and can advocate for and lead change within the workplace. Furthermore, ongoing sustained use of the intervention following implementation is important, and one study suggested that champions are particularly important in the initial implementation phase whereas sustained use occurred as clinicians became more experienced and confident in the use of the intervention (Green et al., 2014).

Limitations and recommendations

One of the main limitations is regarding the heterogeneous nature of the studies that have been conducted in the field. In addition, the focus of the majority of the studies was not to specifically examine the effectiveness of the clinical champions on implementation, but rather the inclusion of a clinical champion was part of a wider implementation strategy. While studies that assess the impact of clinical champions separate from other implementation components would be helpful, either by isolating the inclusion of the champion component or evaluated in comparison to implementation programs without clinical champions, this may not always be feasible. Future work may look to disentangling the roles of champions versus other implementation roles such as external and internal facilitators and how and why these roles may or may not differ. Indeed, the role of champion within implementation interventions themselves needs to be acknowledged whereby many implementation interventions have the role of champion embedded in the standard implementation process yet may not be easily identified in the literature.

Conclusion

This review identified studies that examined the effectiveness of clinical champions or characterized the role of clinical champions in drug and alcohol and mental health settings. Similar to general health care settings, champions appeared to be an important vehicle for facilitating practice changes by overcoming system barriers and enhancing staff engagement. Clinical champions in drug and alcohol settings have been typically selected rather than emergent and although some studies provided face-to-face and online training workshops, details regarding training were most often not provided. Given the key role of clinical champions in implementation research, future studies should provide specific details regarding clinical champion attributes and training and also examine the relevant combination of personal characteristics and training sufficient to facilitate implementation of evidence-based practice in drug and alcohol and mental health settings.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the New South Wales Health Translational Research Grant Scheme (P.H., K.M., A.B.) and a New South Wales Translational Research Fellowship (K.M.).

References

Avalos

L. A.

Raine-Bennett

Chen

Adams

A. S.

Flanagan

(2016). Improved perinatal depression screening, treatment, and outcomes with a universal obstetric program. Obstetrics and Gynecology, 127(5), 917–925. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4972038/pdf/nihms-767481.pdf

Ballard

Corbett

Orrell

Williams

Moniz-Cook

Romeo

Woods

Garrod

Testad

Woodward-Carlton

Wenborn

Knapp

Fossey

(2018). Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: A cluster-randomised controlled trial. PLOS Med, 15(2), Article e1002500. https://doi.org/10.1371/journal.pmed.1002500

Banks

Waugh

Henderson

Sharp

Brown

Oliver

Marland

(2014). Enriching the care of patients with dementia in acute settings? The Dementia Champions Programme in Scotland. Dementia, 13(6), 717–736. https://doi.org/10.1177/1471301213485084

Bauer

Damschroder

Hagedorn

Smith

Kilbourne

(2015). An introduction to implementation science for the non-specialist. BMC Psychology, 3(1), Article 32. https://doi.org/10.1186/s40359-015-0089-9

Bentz

Bayley

Bonin

Fleming

Hollis

Hunt

Siemienczuk

(2007). Provider feedback to improve 5A’s tobacco cessation in primary care: A cluster randomized clinical trial. Nicotine & Tobacco Research, 9(3), 341–349. https://doi.org/10.1080/14622200701188828

Bowman

Luck

Gale

R. C.

Smith

York

L. S.

Asch

(2015). A qualitative evaluation of web-based cancer care quality improvement toolkit use in the Veterans Health Administration. Quality Management in Healthcare, 24(3), 147–161. https://doi.org/10.1097/QMH.0000000000000063

Byers

(2017). The challenges of leading change in health-care delivery from the front-line. Journal of Nursing Management, 25(6), 449–456. https://onlinelibrary.wiley.com/doi/pdf/10.1111/jonm.12342

Chang

E. T.

Rose

D. E.

Yano

E. M.

Wells

K. B.

Metzger

M. E.

Post

E. P.

Lee

M. L.

Rubenstein

L. V.

(2013). Determinants of readiness for primary care-mental health integration (PC-MHI) in the VA Health Care System. Journal of General Internal Medicine, 28(3), 353–362. https://doi.org/10.1007/s11606-012-2217-z

Cohen

Chinman

Hamilton

Whelan

Young

(2013). Using patient-facing kiosks to support quality improvement at mental health clinics. Medical Care, 51(3, Suppl. 1), S13–S20. https://doi.org/10.1097/MLR.0b013e31827da859

10.

Cook

J. M.

Biyanova

Coyne

J. C.

(2009). Comparative case study of diffusion of eye movement desensitization and reprocessing in two clinical settings: Empirically supported treatment status is not enough. Professional Psycholology: Research and Practice, 40(5), 518–524. https://doi.org/10.1037/a0015144

11.

Cranley

L. A.

Cummings

G. G.

Profetto-McGrath

Toth

Estabrooks

C. A.

(2017). Facilitation roles and characteristics associated with research use by healthcare professionals: A scoping review. BMJ Open, 7(8), Article e014384. https://doi.org/10.1136/bmjopen-2016-014384

12.

Dale

Levi

Ward

Grimshaw

J. M.

Jammali-Blasi

D’Este

Griffiths

Quinn

Evans

Cadilhac

Cheung

N. W.

Middleton

(2015). Barriers and enablers to implementing clinical treatment protocols for fever, hyperglycaemia, and swallowing dysfunction in the Quality in Acute Stroke Care (QASC) Project: A mixed methods study. Worldviews on Evidence-Based Nursing, 12(1), 41–50. https://doi.org/10.1111/wvn.12078

13.

Damschroder

L. J.

Hagedorn

H. J.

(2011). A guiding framework and approach for implementation research in substance use disorders treatment. Psychology of Addictive Behaviors, 25(2), 194–205. https://doi.org/10.1037/a0022284

14.

Dimoska

Butow

P. N.

Lynch

Hovey

Agar

Beale

Tattersall

M. H.

(2012). Implementing patient question-prompt lists into routine cancer care. Patient Education and Counseling, 86(2), 252–258. https://doi.org/10.1016/j.pec.2011.04.020

15.

Dopson

FitzGerald

Ferlie

Gabbay

Locock

(2002). No magic targets! Changing clinical practice to become more evidence based. Health Care Management Review, 27(3), 35–47. https://insights.ovid.com/pubmed?pmid=12146782

16.

Dudgeon

King

Howell

Green

Gilbert

Hughes

Lalonde

Angus

Sawka

(2012). Cancer Care Ontario’s experience with implementation of routine physical and psychological symptom distress screening. Psycho-Oncology, 21(4), 357–364. https://onlinelibrary.wiley.com/doi/pdf/10.1002/pon.1918

17.

Eccles

M. P.

Mittman

B. S.

(2006). Welcome to implementation science. Implementation Science, 1, 1. https://doi.org/10.1186/1748-5908-1-1

18.

Forchuk

Martin

M. L.

Jensen

Ouseley

Sealy

Beal

Reynolds

Sharkey

(2013). Integrating an evidence-based intervention into clinical practice: “Transitional relationship model.” Journal of Psychiatric and Mental Health Nursing, 20(7), 584–594. https://doi.org/10.1111/j.1365-2850.2012.01956.x

19.

Gordon

A. J.

Kavanagh

Krumm

Ramgopal

Paidisetty

Aghevli

Goodman

Trafton

Liberto

(2011). Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration. Psychology of Addictive Behaviors, 25(2), 215–224. https://doi.org/10.1037/a0022776

20.

Goren

J. L.

Rose

A. J.

Engle

R. L.

Smith

E. G.

Christopher

M. L.

Rickles

N. M.

Semla

T. P.

McCullough

M. B.

(2016). Organizational characteristics of Veterans Affairs Clinics with high and low utilization of clozapine. Psychiatric Services, 67(11), 1189–1196. https://doi.org/10.1176/appi.ps.201500506

21.

Graham

I. D.

Alvarez

Tetroe

McAuley

Laupacis

(2002). Factors influencing the adoption of blood alternatives to minimize allogeneic transfusion: The perspective of eight Ontario hospitals. Canadian Journal of Surgery, 45(2), 132–140. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3686936/pdf/0450132.pdf

22.

Green

C. A.

McCarty

Mertens

Lynch

F. L.

Hilde

Firemark

Weisner

C. M.

Pating

Anderson

B. M.

(2014). A qualitative study of the adoption of buprenorphine for opioid addiction treatment. Journal of Substance Abuse Treatment, 46(3), 390–401. https://doi.org/10.1016/j.jsat.2013.09.002

23.

Guerrero

E. G.

Heslin

K. C.

Chang

Fenwick

Yano

(2015). Organizational correlates of implementation of colocation of mental health and primary care in the Veterans Health Administration. Administration and Policy in Mental Health and Mental Health Services Research, 42(4), 420–428. https://doi.org/10.1007/s10488-014-0582-0

24.

Hagedorn

H. J.

Wisdom

J. P.

Gerould

Pinsker

Brown

Dawes

Dieperink

Myrick

D. H.

Oliva

E. M.

Wagner

T. H.

Harris

A. H. S.

(2019). Implementing alcohol use disorder pharmacotherapy in primary care settings: A qualitative analysis of provider-identified barriers and impact on implementation outcomes. Addiction Science and Clinical Practice, 14(1), 24. https://doi.org/10.1186/s13722-019-0151-7

25.

Hargraves

White

Frederick

Cinibulk

Peters

Young

Elder

(2017). Implementing SBIRT (Screening, Brief Intervention and Referral to Treatment) in primary care: Lessons learned from a multi-practice evaluation portfolio. Public Health Reviews, 38, 31. https://doi.org/10.1186/s40985-017-0077-0

26.

Harris

Brown

Dawesde

Dieperink

Hugh Myrickhi

Gerould

Wagnerj

Wisdomk

Hagedornfg

(2017). Effects of a multifaceted implementation intervention to increase utilization of pharmacological treatments for alcohol use disorders in the US Veterans Health Administration. Journal of Substance Abuse Treatment, 82, 107–112. https://doi.org/10.1016/j.jsat.2017.09.002

27.

Haynes

L. F.

Korte

J. E.

Holmes

B. E.

Gooden

Matheson

Feaster

D. J.

Leff

J. A.

Wilson

Metsch

L. R.

Schackman

B. R.

(2011). HIV rapid testing in substance abuse treatment: Implementation following a clinical trial. Evaluation and Program Planning, 34(4), 399–406. https://doi.org/10.1016/j.evalprogplan.2011.02.007

28.

Helseth

S. A.

Janssen

Scott

Squires

D. D.

Becker

S. J.

(2018). Training community-based treatment providers to implement contingency management for opioid addiction: Time to and frequency of adoption. Journal of Substance Abuse Treatment, 95, 26–34. https://doi.org/10.1016/j.jsat.2018.09.004

29.

Kathol

R. G.

Butler

McAlpine

D. D.

Kane

R. L.

(2010). Barriers to physical and mental condition integrated service delivery. Psychosomatic Medicine, 72(6), 511–518. https://doi.org/10.1097/PSY.0b013e3181e2c4a0

30.

Kipping

S. M.

De Souza

J. L.

Marshall

L. A.

(2019). Co-creation of the Safewards model in a Forensic Mental Health Care Facility. Issues in Mental Health Nursing, 40(1), 2–7. https://doi.org/10.1080/01612840.2018.1481472

31.

Knight

A. W.

Szucs

Dhillon

Lembke

Mitchell

(2014). The eCollaborative: Using a quality improvement collaborative to implement the National eHealth Record System in Australian primary care practices. International Journal for Quality in Health Care, 26(4), 411–417. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4126615/pdf/mzu059.pdf

32.

Leathers

S. J.

Spielfogel

J. E.

Blakey

Christian

Atkins

M. S.

(2016). The effect of a change agent on use of evidence-based mental health practices. Administration and Policy in Mental Health and Mental Health Services Research, 43(5), 768–782. https://doi.org/10.1007/s10488-015-0694-1

33.

Louie

Barrett

Baillie

Haber

Morley

K. C.

(2020). Implementation of evidence-based practice for alcohol and substance use disorders: Protocol for systematic review. Systematic Reviews, 9, 25. https://doi.org/10.1186/s13643-020-1285-0

34.

Louie

Giannopoulos

Baillie

Uribe

Byrne

Deady

Teesson

Baker

Haber

P. S.

Morley

K. C.

(2018). Translating evidence-based practice for managing comorbid substance use and mental illness using a multimodal training package. Journal of Dual Diagnosis, 14, 111–119. https://doi.org/10.1080/15504263.2018.1437496

35.

McCabe

M. P.

Karantzas

G. C.

Mrkic

Mellor

Davison

T. E.

(2013). A randomized control trial to evaluate the beyondblue depression training program: Does it lead to better recognition of depression? International Journal of Geriatric Psychiatry, 28(3), 221–226. https://doi.org/10.1002/gps.3809

36.

Miech

E. J.

Rattray

N. A.

Flanagan

M. E.

Damschroder

Schmid

A. A.

Damush

T. M.

(2018). Inside help: An integrative review of champions in healthcare-related implementation. SAGE Open Medicine, 6, 2050312118773261. https://doi.org/10.1177/2050312118773261

37.

Miller

W. R.

Yahne

C. E.

Moyers

T. B.

Martinez

Pirritano

(2004). A randomized trial of methods to help clinicians learn motivational interviewing. Journal of Consulting and Clinical Psychology, 72(6), 1050–1062.

38.

Moher

Liberati

Tetzlaff

Altman

D. G.

(2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Open Medicine, 3(3), e123–e130.

39.

O’Sullivan

P. S.

Yuan

Satre

D. D.

Wamsley

Satterfield

(2018). A sequential implementation model for workforce development: A case study of medical residency training for substance use concerns. Teaching and Learning in Medicine, 30(1), 84–94. https://doi.org/10.1080/10401334.2017.1314216

40.

Pigot

Miller

C. E.

Brockman

Grenyer

B. F. S.

(2019). Barriers and facilitators to the implementation of a stepped care intervention for personality disorder in mental health services. Personality and Mental Health, 13(4), 230–238. https://doi.org/10.1002/pmh.1467

41.

Powell

B. J.

Proctor

E. K.

Glass

J. E.

(2014). A systematic review of strategies for implementing empirically supported mental health interventions. Research on Social Work Practice, 24(2), 192–212. https://doi.org/10.1177/1049731513505778

42.

Rangachari

Madaio

Rethemeyer

R. K.

Wagner

Hall

Roy

Rissing

(2015). The evolution of knowledge exchanges enabling successful practice change in two intensive care units. Health Care Management Review, 40(1), 65–78. https://doi.org/10.1097/hmr.0000000000000001

43.

Rosenberg

R. E.

Klejmont

Gallen

Fuller

Dugan

Budin

Olsen-Gallagher

(2016). Making comfort count: Using quality improvement to promote pediatric procedural pain management. Hospital Pediatrics, 6(6), 359–368. http://hosppeds.aappublications.org/content/hosppeds/6/6/359.full.pdf

44.

Rycroft-Malone

Gradinger

Owen Griffiths

Anderson

Crane

R. S.

Gibson

Mercer

S. W.

Kuyken

(2019). “Mind the gaps”: The accessibility and implementation of an effective depression relapse prevention programme in UK NHS services: Learning from mindfulness-based cognitive therapy through a mixed-methods study. BMJ Open, 9(9), Article e026244. https://doi.org/10.1136/bmjopen-2018-026244

45.

Saunders

E. C.

Kim

McGovers

M. P.

(2014). Substance abuse treatment implementation research. Journal of Substance Abuse Treatment, 44(1), 1–3.

46.

Schorr

Odden

Evans

Escobar

G. J.

Gandhi

Townsend

Levy

(2016). Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical–surgical wards. Journal of Hospital Medicine, 11(Suppl. 1), S32–S39. https://doi.org/10.1002/jhm.2656

47.

Shumway

Mangurian

Carraher

Momenzadeh

Leary

Lee

Dilley

(2018). Increasing HIV testing in inpatient psychiatry. Psychosomatics, 59(2), 186–192. https://doi.org/10.1016/j.psym.2017.10.007

48.

Sunderji

Ion

Zhu

Perivolaris

Rodie

Mulsant

(2019). Challenges in conducting research on collaborative mental health care: A qualitative study. CMAJ Open, 7(2), E405–E414. https://doi.org/10.9778/cmajo.20180172

49.

Thomason

S. S.

Powell-Cope

Peterson

M. J.

Guihan

Wallen

E. S.

Olney

C. M.

Bates-Jensen

(2016). A multisite quality improvement project to standardize the assessment of pressure ulcer healing in veterans with spinal cord injuries/disorders. Advances in Skin & Wound Care, 29(6), 269–276. https://doi.org/10.1097/01.ASW.0000482283.85306.8f

50.

Whiteford

H. A.

Ferrari

A. J.

Degenhardt

Feigin

V. L.

Vos

(2015). The global burden of mental, neurological and substance use disorders: An analysis from the Global Burden of Disease Study 2010. PLOS ONE, 10(2), Article e0116820. https://doi.org/10.1371/journal.pone.0116820

51.

Williams

A. M.

Toye

Deas

Fairclough

Curro

Oldham

(2012). Evaluating the feasibility and effect of using a hospital-wide coordinated approach to introduce evidence-based changes for pain management. Pain Management Nursing, 13(4), 202–214. https://doi.org/10.1016/j.pmn.2010.08.001

52.

Williams

T. A.

Leslie

G. D.

Leen

Mills

Dobb

G. J.

(2013). Reducing interruptions to continuous enteral nutrition in the intensive care unit: A comparative study. Journal of Clinical Nursing, 22(19–20), 2838–2848. https://onlinelibrary.wiley.com/doi/pdf/10.1111/jocn.12068

The role of clinical champions in facilitating the use of evidence-based practice in drug and alcohol and mental health settings: A systematic review

Abstract

Background:

Methods:

Results:

Conclusions:

Plain language abstract

Keywords

Methods

Eligibility criteria

Search strategy

Study selection

Data extraction and synthesis

Results

Study details

Study design

Outcomes

Who were the clinical champions?

Champion training

Clinical champion role and responsibilities

Effectiveness of champions

Discussion

Limitations and recommendations

Conclusion

Footnotes

Declaration of conflicting interests

Funding

References