title: Factors influencing the implementation of a lifestyle counseling program in patients with venous leg ulcers: a multiple case study.
abstract: BACKGROUND
  Implementation of lifestyle interventions in patient care is a major challenge. Understanding factors that influence implementation is a first step in programs to enhance uptake of these interventions. A lifestyle-counseling intervention, Lively Legs, delivered by trained nurses, can effectively improve the lifestyle in patients with venous leg ulcers. The aim of this study was to identify factors that hindered or facilitated implementation of this intervention in outpatient dermatology clinics and in home care.
  
  
  METHODS
  A mixed-methods multiple case study in five purposefully selected healthcare settings in the Netherlands was conducted. Measurements to identify influencing factors before and after implementation of Lively Legs included interviews, focus groups, questionnaires, and nurses' registration. Analyses focused on qualitative data as the main data source. All data were compared across multiple cases to draw conclusions from the study as a whole.
  
  
  RESULTS
  A total of 53 patients enrolled in the Lively Legs program, which was delivered by 12 trained nurses. Barriers for implementation were mainly organizational. It was difficult to effectively organize reaching and recruiting patients for the program, especially in home care. Main barriers were a lack of a standardized healthcare delivery process, insufficient nursing time, and a lack of motivated nurses to deliver the program. Facilitating factors were nurse-driven coordination of care and a standardized care process to tie Lively Legs into, as this resulted in better patient recruitment and better program implementation.
  
  
  CONCLUSIONS
  This study identified a range of factors influencing the implementation of a lifestyle-counseling program, mainly related to the organization of healthcare. Using a case study method proved valuable in obtaining insight into influencing factors for implementation. This study also shed light on a more general issue, which is that leg ulcer care is often fragmented, indicating that quality improvement is needed.
authors.affiliation: Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands. i.vandeglind@iq.umcn.nl
authors.forename: Irene M
authors.initials: IM
authors.lastname: van de Glind
authors.forename: Maud M
authors.initials: MM
authors.lastname: Heinen
authors.forename: Andrea W
authors.initials: AW
authors.lastname: Evers
authors.forename: Michel
authors.initials: M
authors.lastname: Wensing
authors.forename: Theo
authors.initials: T
authors.lastname: van Achterberg
mesh_terms: D002985:Clinical Protocols; D002986:Clinical Trials as Topic / Q000379:methods*; D003376:Counseling / Q000458:organization & administration*; D003625:Data Collection; D015444:Exercise; D015438:Health Behavior; D006293:Health Promotion / Q000458:organization & administration*; D006801:Humans; D008019:Life Style; D009426:Netherlands; D009726:Nurses; D010353:Patient Education as Topic / Q000458:organization & administration; D036301:Qualitative Research; D053828:Stockings, Compression; D014647:Varicose Ulcer / Q000517:prevention & control* / Q000628:therapy*