A key challenge facing the global health community is how to use evidence-based practices within a real-world setting.1 The gap between the way practitioners act and what evidence shows as best practice affects the outcomes for individuals receiving healthcare services. Implementation studies have received considerable attention over the previous decades, drawing from the evidence in clinical practice.2 For the purpose of this review, implementation is defined as “a specified set of activities designed to put into practice an activity or program of known dimensions”.3(p.5) According to this definition, implementation is a planned and purposeful process, with active ingredients that push the implementation forward. An implementation process should be geared toward overcoming barriers and making use of known facilitators in the environment or context.2
The usual challenges of establishing new services from other settings include mismatches between the characteristics of the new population, the local community and the original program. Particular objectives, approaches or activities may be too politically charged or controversial for the new local community, or they may be irrelevant in the new setting. It is also possible that an agency may lack the funding, staffing, expertise or other resources needed to implement the program as originally designed.4
Using existing scientific knowledge and translating into routine clinical care is challenging. This is the case with Individual Placement and Support (IPS), which is a standardized approach of supported employment for people with severe mental illness so they may gain and maintain competitive jobs in the labor market. Eight evidence-based principles underpin the IPS approach: i) focus upon competitive employment, ii) eligibility based on client choice, ii) integration between mental health and employment services, iv) support guided by clients’ preferences, v) personal financial counseling, vi) rapid job search, vii) systematic job development, and viii) time-unlimited, individualized job support.5 The IPS approach is internationally recognized as evidence-based practice, and the most effective and efficient way of supporting this population.6-8 Still, to our knowledge, no country has successfully implemented IPS as a mainstream service delivery across an entire country. The IPS approach is official policy in some countries (e.g. England) and some regions (e.g. in Spain and Italy), but the degree of implementation varies.9 The context in which IPS is provided varies. Often, agencies from the health and welfare sectors collaborate, purposing to integrate vocational and clinical interventions. For this review, sectors will include all services, agencies and providers involved in IPS.
It is well documented that the employment rate for individuals with severe mental illness is very low,10-14 measured at six to seven times lower than individuals with no mental disorder.15 Reviews of mental health and employment policies in Organisation for Economic Co-operation and Development (OECD) countries highlight shortcomings in the way these countries address sick leave, disability and joblessness among persons with mental health conditions.16 This is a challenge for societies, but first and foremost for individuals reporting that work is often essential to their recovery.17 There are numerous benefits of employment for individuals with severe mental illness18,19 including financial benefits, improved self-esteem, improved well-being, improved social contacts and independence.20-23 As a result, it is not surprising that the majority of people with severe mental illness consistently report that they want to work.14,24 Therefore, there is reason to be concerned about the gap between the evidence-based practice and the lack of implementation in routine clinical care.
To gain an understanding of the gap between research and practice, this scoping review will focus on the attempts to implement IPS for people with mental health conditions. The implementation process has been described in existing studies.25-28 A variety of challenges to implementing IPS have been reported,29,30 with barriers identified at the contextual, organizational and individual levels. Key challenges at the contextual level include the lack of stable funding to support IPS31 and the collaboration required between different agencies, which can be problematic because of different regulatory structures, incentives and goals.32 Other challenges are organizational factors and the cultural friction that can exist within and between departments and organizations, such as between the health and welfare sectors. Modifications to organizational culture are fundamental in the development and sustainability of new and innovative services.33
Participants in the implementation processes are heterogeneous groups of stakeholders. A preliminary review of the existing literature shows participants to be managers from health and welfare sectors, project leaders, practitioners, decision makers, employment specialists, service users and more.25,34 This scoping review will include any stakeholders/actors involved in the implementation process, including employees from the health and welfare sectors, those delivering IPS and receivers of IPS services.
To promote the implementation of this evidence-based practice, an overview of the existing knowledge on attempts to implement IPS internationally, including facilitators and barriers to the implementation process, will be reviewed. To continue the knowledge development within this field, we also need an overview of theoretical frameworks and methodological approaches used within the existing implementation studies. A preliminary search of PROSPERO, PsycINFO, MEDLINE (PubMed), the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports revealed few existing reviews on this topic. No scoping reviews were available or currently under development. There are several reviews investigating the efficacy of IPS. For the implementation process, previous reviews have focused on a specific country or an area within a country such as England,27 Australia or New Zealand.35 One systematic review was identified that investigated the international literature on the implementation of IPS.30 The review identified facilitators and barriers to implementation. The authors sought to evaluate research on IPS implementation and gain an overview of the methods and theories used. The searches were conducted in 2013 and subsequently in April 2015. This scoping review will differ from the Bonfils et al.30 review by adding participants to the searches. Internationally, the development of IPS has grown rapidly and a new review is appropriate.
The objective of this scoping review is to identify and map existing evidence/knowledge on the methods and approaches used to implement IPS at scale in the health and welfare sector, and the frameworks and methodological approaches used in implementation studies, as well as to identify knowledge gaps that are important for further research.
- Which methods and approaches are used to implement IPS at scale in the real world?
- Which factors enable the move from a project to mainstream practice for IPS?
- In what context (specialist healthcare setting, primary healthcare setting, welfare setting) is IPS provided?
- What is/are the implementation framework(s) used in the IPS implementation literature?
- Which methodological approaches are used in existing implementation studies?
This review will include studies reporting on the implementation of IPS for people with mental health conditions (not only severe mental illness). Recent IPS studies have included patients with moderate to severe mental illness (e.g. Reme et al.36). We believe the implementation process will share similarities independent of the severity of the mental health conditions of those receiving IPS. This review will include studies that focus on the implementation process of IPS as reported by heterogeneous stakeholders. We have defined two groups of participants for this scoping review: i) health and welfare employees (e.g. managers, project leaders, practitioners, decision makers or employment specialists) and ii) IPS receivers (e.g. clients, job seekers, patients).
This review will include studies that focus on the concepts of implementation and IPS. Implementation is part of a diffusion-dissemination-implementation continuum, where implementation is the process of putting to use or integrating new practices within a setting.37 For this scoping review, implementation is “a specified set of activities designed to put into practice an activity or program of known dimensions”.3(p.5) Implementation should result in the faithful translation of research-based evidence into mainstream practice at scale. An evidence-based scale-up will “target health delivery units within the same, or very similar settings, under which the intervention has already been tested”.38(p.3)
Individual Placement and Support is a standardized approach of supported employment, designed to assist people with mental health conditions to gain and maintain competitive jobs in the labor market. The IPS approach is both interprofessional and intersectoral. Two IPS Fidelity Scales exist to measure program fidelity and validity.39,40 Each scale assesses the critical ingredients of IPS based on its underlying principles and methods. The scale items provide concrete indications that the practice is being implemented as intended. The IPS Fidelity Scales measure the adherence to the principles of IPS and are key factors in ensuring the success of the IPS practice.41 Studies included in this scoping review may report on fidelity scale measurement to ensure their adherence to the IPS model.
Internationally, there are considerable differences between health and social care, employment services and welfare systems.42 The intervention of IPS integrates psychiatric treatment with welfare and employment services. However, IPS can be implemented within different contexts. In the majority of countries, the health sector has led the implementation of IPS, whereas in other countries, the welfare sector has led implementation. This review will include studies where IPS is provided within a health or welfare sector setting (e.g. specialist health care [psychosis unit], primary health care [municipal mental care] or social/welfare services [employment office]). The concept of health and welfare sectors includes all health, social and welfare services. Additionally, a sector includes contexts outside the clinical setting, such as bureaucratic and professional offices.
Types of sources
This scoping review will consider research with different study designs, including (but not limited to) case-control studies, qualitative studies, pragmatic or naturalistic trials, quantitative studies and mixed method studies. Randomized controlled trials (RCT) will be excluded as we are searching for studies in a non RCT-environment to explore the transition from research to mainstream, “real-world” practice. This scoping review will consider research presented in research articles, editorials and feature articles in peer-reviewed journals. Gray literature such as political documents, government recommendations, service delivery reports, theses and conference abstracts will be considered. Studies published from 1993 will be included, because to the best of our knowledge, no IPS implementation studies were reported before that year.43 Studies that have abstracts in English, German or Scandinavian languages will be considered.
The proposed systematic review will be conducted in accordance with the JBI methodology for scoping reviews.44
We will follow a three-step search strategy to trace published studies by including:
- An initial limited search in PROSPERO, MEDLINE (PubMed), CINAHL and PsycINFO to identify relevant key words and search terms used in titles and abstracts in studies published within the topic.
- Based on search terms identified in the initial search, specific search strategies will be developed with assistance from a librarian to fit with the following databases: MEDLINE (PubMed), Cochrane Central Register of Controlled Trials, Embase, PsycINFO, Base, OpenGrey and CINAHL, from 1993 to the present.
- The reference lists of all included studies will be searched, and a citation search of included studies will be performed through Google Scholar to identify eligible studies that may not have been found through the previous search strategy. Authors of included studies will be contacted if further information about the study is required.
The preliminary search strategy for MEDLINE is presented in Appendix I and includes search terms related to participants (health and welfare sector employers and IPS recipients) and concept (implementation and IPS). As the context is “any context”, we did not include the contexts in the searches. Relevant MeSH terms and headings will be identified and used where required. The language may change slightly depending on the database; however, the main keywords will be used throughout. Only English search terms will be used in the search strategies.
Following the searches, all identified citations will be uploaded into EndNote X7.8 (Clarivate Analytics, PA, USA) and duplicates removed. One reviewer (CM) will perform an initial screening of titles and abstracts, and exclude studies that clearly do not meet the inclusion criteria. Titles and abstracts will then be uploaded into Rayyan (Qatar Computing Research Institute, Doha, Qatar)45 and screened by two independent reviewers (CM and BB) for assessment against inclusion criteria for the review. Studies not meeting the inclusion criteria will be excluded.
Potentially relevant studies will be retrieved in full and assessed in detail against the inclusion criteria by two independent reviewers (CM and BB). Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussions or by involving a third reviewer for consensus (MR or AM). The results of the searches will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.46
Data will be extracted from papers included in the scoping review by two reviewers (CM and BB) using data extraction tables developed by the reviewers (Appendix II). The data extracted will include specific details about the population, concept, context, study methods and key findings relevant to the review objective. Furthermore, findings that are considered relevant for the objective of this review will be charted, including information on methods, strategies and activities to put IPS into practice. The draft of data extraction tables will be modified and revised as necessary during the process of extracting data from each included study to leave openness for inclusion of additional unforeseen data that may be relevant for our inquiry. Modifications will be detailed in the full scoping review report. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer (MR or AM). A qualitative content analytical technique will be used to facilitate the mapping of the results. One reviewer (CM) will conduct the analysis in cooperation with the rest of the review team.
The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objective of this scoping review. A descriptive summary will accompany the tabulated and/or charted results and will describe how the results relate to the reviews objective and question.
The scoping review course leaders, professor Lisbeth Uhrenfeldt and professor Preben Ulrich Pedersen, at the Faculty of Nursing and Health Sciences at Nord University, Norway, for comments on the manuscript.
The study is funded by Nord University, Norway, and Nordland Hospital Trust, Norway. The funders were not involved in the content for the study.
Appendix I: Search strategy for MEDLINE (Ovid)
Appendix II: Data extraction table
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