Barriers and Facilitators to Adopting a Risk Assessment and Management Decision Support Approach For Safety Concerns of Older Adults: a Multimethods Study

Barriers and Facilitators to Adopting a Risk Assessment and Management Decision Support Approach For Safety Concerns of Older Adults: a Multimethods Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers and Facilitators to Adopting a Risk Assessment and Management Decision Support Approach For Safety Concerns of Older Adults: a Multimethods Study Heather MacLeod, Véronique Provencher, Nathalie Veillette, Jennifer Klein, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8865683/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background The Living with Risk: Decision Support Approach (LwR:DSA) was developed to address the lack of structured approaches for assessing and managing risk among healthcare professionals (HCPs) supporting older adults with perceived safety concerns. Early use of the LwR:DSA demonstrated potential to expand person-centred, balanced discussions of risk; however, strategies to support its adoption in hospital and community settings remain unclear. This study aimed to describe LwR:DSA adoption and identify multilevel barriers and facilitators influencing its adoption so that the tool and implementation strategies could be appropriately tailored. Methods A multimethod implementation study was conducted. Quantitative survey data were analysed descriptively, and qualitative interview data were analysed using reflexive content analysis guided by the five domains of the Consolidated Framework for Implementation Research (CFIR). Findings were integrated and categorized across the five CFIR domains to identify multilevel determinants influencing adoption. Results Of 26 participants, eighty percent adopted the LwR:DSA at least once during an eight-week implementation period and identified 20 determinants across all CFIR domains. Six constructs acted solely as facilitators, one as a barrier, and thirteen as mixed determinants. Key determinants of LwR:DSA adoption were knowing with whom to use the LwR:DSA (Outer Setting), knowing how to integrate into practice, using the LwR:DSA as a team, having supportive leadership, working in an innovative workplace with good relationships with colleagues (Inner Setting), finding the LwR:DSA easy to use (Innovation), having an in-depth foundational knowledge related to the LwR:DSA (HCPs) and using champions (Implementation Process). Conclusions Application of the CFIR provided a comprehensive understanding of multilevel factors influencing LwR:DSA adoption across hospital and community settings. These determinants can be leveraged to inform the selection and tailoring of implementation strategies to enhance uptake and sustainability. Embedding these determinants within future implementation efforts offers a practical pathway to strengthen person-centred, risk-informed decision-making practices across geriatric care contexts. risk assessment risk management clinical decision-making Consolidated Framework for Implementation Research adoption barriers and facilitators older adults safety concerns shared decision-making. Background Illness, injuries and/or disabilities put older adults at increased risk for adverse outcomes and potential safety concerns as they strive to age in place. Healthcare professionals (HCPs) often attempt to prevent harm for older adults. In doing so, they often overestimate risk and focus on extreme harm [ 1 ] and use a quick ‘gut reaction’ approach to evaluating risk [ 2 ]. It is not surprising that HCPs are reluctant to support older adults to remain at home if they perceive risks as only negative. This reluctance can lead to moral distress for HCPs [ 3 ] and older adults feeling coerced to accept undesirable discharge plans (i.e. discharge destinations other than home) when they do not align with their preferences and goals of care [ 4 ]. Current risk assessment and management guidance are focused on specific patient populations (e.g. people with mental health diagnoses [ 5 ]), risky activities (e.g. potential for fires while cooking [ 6 ]) or provide general theoretical overviews [ 7 ]. These frameworks lack a comprehensive, systematic or practical approach to risk assessment and management that optimizes an older adult’s safety, autonomy and resilience. The Living with Risk: Decision Support Approach (LwR:DSA) was developed to address this clinical gap by broadening and balancing HCPs’ approach to risk assessment to be more supportive of older adults’ preferences and goals of remaining at home [ 8 ]. The LwR:DSA was developed based on best practices in the community [ 9 ], subsequently adapted for hospital contexts and validated in both hospital and community settings [ 10 ]. In practice, the LwR:DSA guides HCPs in collaboration with older adults, to clarify the safety concern and identify its causes, context, and consequences. HCPs are encouraged to consider both the benefits and negative consequences of potential decisions from the perspectives of the older adult, their caregivers, and the healthcare team. These considerations inform the co-creation of solutions to reduce the older adult’s risk for negative outcomes while acknowledging the emotional, social, and physical benefits of decisions that may appear risky from the HCPs point of view. In these ways, the LwR:DSA is person-centred, involving the older adult throughout the process. Implementing the LwR:DSA in care discussions has the potential to promote more intentional, comprehensive, and balanced conversations among HCPs, older adults, and caregivers about potential risks in different living settings. However, adopting new practices into healthcare can be delayed [ 11 ], not sustained [ 12 ], or only partially adopted [ 13 ] when contextual factors influencing uptake are not adequately addressed [ 14 ]. Emerging implementation research suggests that non-tailored, low intensity ‘starter’ implementation strategies may be used to support initial uptake, with more intensive tailoring occurring downstream as barriers and facilitators are better understood [ 15 – 17 ]. Understanding the multi-level determinants of adoption therefore remains a critical step in moving evidence into practice prior to evaluating outcomes as it informs the refinement and tailoring of context-specific implementation strategies [ 18 ]. The aims of this study were to (1) describe the adoption of the LwR:DSA in the hospital and community settings following the use of pre-selected implementation strategies and (2) identify and understand the multi-level determinants (barriers and facilitators) influencing its adoption into practice to inform the refinement, tailoring or development of implementation strategies. Methods This multimethod implementation study gathered quantitative and qualitative data over three phases. The Consolidated Framework for Implementation Research 1.0 [ 19 ] was selected to determine the barriers and facilitators of adoption as using a theoretical framework ensures a shared language for the generalizability of the findings [ 20 ]. The CFIR was chosen as it comprehensively highlights multi-level factors that typically influence implementation based on the synthesis of 19 implementation models [ 21 ]. More specifically, 39 constructs are grouped across five domains (Outer Setting, Inner Setting, Innovation, Individual and Implementation Process) [ 19 ]. The five domains pertinent to this study were characteristics related to: (1) the HCP participants’ clients (Outer Setting); (2) the hospital and/or community clinical settings (Inner Setting); (3) the LwR:DSA (Innovation); (4) the multidisciplinary HCPs (Individual); and, (5) the way in which participants adopted the LwR:DSA (Implementation Process). Participants We aimed to recruit a convenience sample of 25–30 multidisciplinary English- or French-speaking HCPs from across Canada working with older adults in the hospital and community settings over five months (March–July 2022) using a variety of methods (recruitment emails to professional contacts, and recruitment posters in presentations, organizations’ newsletters, discussion boards and community of practices). Within networks, individuals were encouraged to forward information to potentially interested participants. HCPs working under supervision (i.e. a provisional license) or currently using the LwR:DSA were excluded. Participants received a $ 25 e-gift card for participating in the individual interview and an additional $ 25 e-gift card if they participated in the focus group. The positionality of the researcher team included that they were clinician-researchers, had experience in qualitative analysis, and some were involved in previous research with the LwR:DSA. Procedures The study took place across three phases (Pre-Use, Use, and Post-Use) between March 2022 and July 2023. Pre-Use: Following informed consent, participants completed a 60-minute virtual training session that overviewed the risk assessment process and the LwR:DSA. Use: Participants then used the LwR:DSA in their clinical practice for eight weeks supported by four pre-selected low-intensity implementation strategies: (1) six, 10-minute brief training videos; (2) an instruction guide; (3) three worksheets; and, (4) bi-monthly researcher initiated emails to provide reminders, clarifications and opportunities to ask questions. These foundational pre-selected strategies were intentionally non-tailored and were designed to support initial adoption by addressing common barriers to new innovations, particularly lack of knowledge and skill [ 22 ]. Strategy selection was also informed from the validation and adaptation of the LwR:DSA [ 9 ] and by literature on the implementation of decision support tools and shared decision-making interventions [ 23 – 33 ]. The eight-week time frame was chosen as a reasonable time to (1) learn how to use the LwR:DSA, (2) integrate it into practice, (3) use it several times, while (4) minimizing participant burden. The participants were encouraged to use the LwR:DSA in a way that was most clinically relevant for them. The eight weeks was not continuous to accommodate sick leave and/or vacation time. Post-Use: Participants took part in an individual 60-minute virtual interview within three weeks of completing use. Data Collection Quantitative Participant demographic quantitative data was obtained via Microsoft Forms during Phase 1 (Pre-Use) when participants registered for the study. The adoption level quantitative data was confirmed with participants during the Phase 3 virtual individual interview (Post-Use). Adoption was defined as participants’ action of using the LwR:DSA in practice based on the behavioural components of Proctor et al.’s [ 34 ] definition of adoption. Adoption was determined by participant self-report of the total number of clients with whom they used the LwR:DSA over the eight weeks. Participants recorded weekly on a study log: 1) number of clients with whom they used the LwR:DSA with and 2) number with whom they could have used the LwR:DSA but did not (including the reason for not using it). The self-reported adoption number was supported by submitted study logs, providing partial behavioural verification. Qualitative Qualitative data was gathered during the Phase 3 (Post-Use) virtual individual interview. Interview questions (see Supplementary Files) were 1) adapted from the CFIR Interview Guide ( https://cfirguide.org/guide/app/#/ ) and then 2) pilot-tested with three HCPs who were familiar with the LwR:DSA but did not participate in the study, with no suggested changes. In the interviews, we sought to elicit barriers and facilitators to adopting the LwR:DSA following its use. Sample questions included ‘what do you perceive were factors that facilitated/were barriers for LwR:DSA use in your clinical context?’ , ‘what advantages/disadvantages does the LwR:DSA have compared to current practice?’ . The first author (HM) conducted virtual 30–60 min interviews. Notes were taking during and after the interviews. Interviews were audio recorded and transcribed verbatim by a professional transcriptionist. Transcripts were uploaded to NVivo 14 [ 35 ] to facilitate coding of the data. Data Analysis Quantitative data were analysed using descriptive statistics in Excel [ 36 ]. Qualitative data were analysed by the first author (HM), with 18% of interviews co-coded by a qualitative researcher external to the research team. Any dissonance in coding was discussed for consensus and all coding was reviewed with three members of the research team (DK, VP, KL) for input following the four analytic strategies of reflexive content analysis [ 37 ]: (1) transcripts were read for accuracy against the audio recording and then re-read several times to become familiar with the data; (2) data was then inductively coded line by line using codes that represented the words and ideas from participants; (3) codes were reviewed and revised; then (4) organized into an analysis structure of subcategories and then deductively mapped onto the categories (constructs and subconstructs) from the CFIR framework. Additional categories were made for codes/subcategories outside of the CFIR constructs. Researcher reflexivity occurred and was recorded throughout the analysis. As well, analysis was reviewed and validated with 38% of participants in a focus group. Results Participants Twenty-six participants consented to the study. The majority were women (92%), working in the community (54%), with 16 + years of experience (61%) (Table 1 ). Participants represented a variety of disciplines with the majority being occupational therapists (31%) and nurses (27%). One participant withdrew prior to starting the study and contact was lost for three participants (three hospital nurses) despite three email contacts. Adoption Eighty percent of participants adopted the LwR:DSA with varying frequency over the eight weeks (Table 2 ). Seventy percent of these participants indicated they could have used the LwR:DSA more, with there being no difference across practice settings (Table 2 ). Table 1 Participant Demographics (N = 26) Demographic Category Community (n) Hospital (n) Total (n) % Gender (self-reported) Women 12 12 24 92 Men 2 0 2 8 Discipline OT 6 2 8 31 RN 2 5 7 27 PT 3 1 4 15 SW 2 2 4 15 Other* 1 2 3 12 Years of experience Average 22 years 16 years 18 years Range 1.5–43 years 2–25 years 1.5–43 years < 5 2 1 3 12 5–10 2 3 5 19 11–15 2 2 8 16–20 2 2 4 15 21–25 3 4 7 27 25+ 5 0 5 19 Note. OT: Occupational Therapist, RN: Registered Nurse, PT: Physiotherapist, SW: Social Worker *Other includes Nurse Practitioner, Medical Doctor, Recreational Therapist Table 2 Implementation Outcome: Adoption Level of Adoption Community (n) Hospital (n) Total (n) % Adopted (range of 1–16 times over eight weeks) 12 8 20 80 Not Adopted 1 1 2 8 Could have adopted more 7 7 14 70 Unknown due to Lost contact 0 3 3 12 Barriers and Facilitators Following the 8-week trial period, participants highlighted 20 determinants to using the LwR:DSA in practice across all five CFIR domains (Table 3 ). While six constructs were identified as being only facilitators and one construct as being only a barrier, 13 constructs were identified as both a barrier and a facilitator. Table 4 provides select quotes per CFIR construct. Barriers and facilitators are discussed next by CFIR Domain and corresponding constructs . Table 3 Determinants (Facilitator vs Barrier) of Adoption by CFIR Domains and Constructs CFIR Domains Facilitator Constructs Barrier Constructs Barrier and Facilitator Constructs HCPs’ Clients (Outer Setting) - - Client Needs & Resources Hospital & Community Practice Setting (Inner Setting) Networks & Communication Learning Climate Leadership Engagement Access to Information Culture Tension for Change Compatibility Relative Priority Available Resources LwR:DSA (Innovation) Evidence Strength & Quality Cost - Relative Advantage Adaptability Complexity Design Quality & Packaging HCPs (Individual) - - Knowledge & Beliefs about the Innovation Other Personal Attributes Process of LwR:DSA Adoption (Implementation Process) Engaging - Executing ‘-‘ indicates no identified construct Table 4 Examples of Barrier and Facilitator Quotes by CFIR Domains CFIR Domain Barrier Quote Facilitator Quote Characteristics of the HCPs’ Clients Client known to HCP (client needs and resources) : “[For] some people it just wasn’t appropriate or necessary because I had previously known them and was continuing to work with them, and it just wasn’t a logical fit .” Client with risks (client needs and resources) : “ If I was choosing which type of client to complete this with, I feel that I’d be more inclined to use it with ones where I anticipated that the risk status was higher or more complicated to help me map out all of the different factors.” Characteristics of the Hospital and Community Practice Setting Time (Compatibility) : “I guess the burden of workload sort of coincides with time but even if it only takes a few extra minutes per client to add an additional worksheet or additional documentation sometimes just the weight of that extra burden and taking on an extra task regardless of how quantitatively it may not be that much, I feel that healthcare clinicians especially at this point in time, sort of post-pandemic, do not have the capacity to add any extra burden regardless of how much time it actually needs.” Competing priorities (Relative Priority) : “ I think maybe a reason why I didn’t bring it up with the team or used it more formally is because of the pressures that are right now on the system and how burnt out and exhausted people are. I think trying to bring in a brand-new tool and trying to educate everyone on something new when people are already feeling so exhausted, it’s maybe not the right time.” Collaborative teams (Networks and Communication) : “I think having like a supportive work environment where you feel you can bring up these concerns, it makes it a little bit easier to have those kinds of discussions.” Innovative (Culture): “ So I think that generally my work environment is very open to trying new things and seeing how we can best support our patient population. So, in one case, I think overall the work environment is really supportive and interested in innovative ways to address things.” Integrating into practice (Compatibility): “ Well, I think it wasn’t really a big stretch from what I was already doing. So, it was just a different way to frame it. So, it didn’t take a lot of extra time, like maybe a bit, to fill out forms and stuff like that but it was something that I’m already asking about and I’m already considering and so I think that really allowed me to use the tool.” Dissatisfied with current practice (Tension for change ): “ I was dissatisfied with how I was doing that [risk assessment] previously…it didn't sit well with me the way I was doing it before…it wasn't satisfying, I didn't feel like we'd had a good conversation.” Characteristics related to the LwR:DSA Confusing (Complexity) : “Well I found it a little bit confusing. Trying to figure what is the difference between causes and consequences. That puzzled me sort of...I was always having to go back and review that and like try to make sense of it in my brain. It didn’t come to me naturally.” Design Quality : “ Top notch! On the quality of the documents and worksheets. It was clear. The video too.” Straight forward (Complexity) : “Oh, I thought they [supporting materials] were really helpful. Yeah, very, very helpful. Very straight forward. Very helpful. In the actual fillable thing is, you know, helpful…So it's designed nicely. It's easy to read.… But, yeah, easy to use, straightforward. The materials supporting it were good. All of that, I think is excellent.” Benefit of using LwR:DSA (Relative advantage) : “ I think because of the frequency of use, for sure, and because I was having outcomes with the tool every time, right? Because I saw the outcome every time I used the tool, I realized it’s applicability at that point…. If I was to use the tool and not get anything out of it, I’d be like well I’m just using a tool, right? But because I was using a tool and I was still finding a solution; it was more of a reason for me to use it.” Characteristics related to the HCPs Change is difficult (Other personal attributes) : “And I'm not good at incorporating new things. I'm not good at kind of using standardized tools. My QI colleagues are much better at that. So, it would be an interesting process to think about how to incorporate it more fully, and how to use it more and to remind myself to use it.” Lack of knowledge about risk ( Knowledge and belief of LwR:DSA and risk ): “This is the type of thing that I think we really need and especially as we’re trying to recruit more and more people into healthcare and so having a tool early in your career and getting that mentality early in your career that risk is okay and trying to provide education about risk sooner than later, I think is incredibly beneficial.” Characteristics related to the Implementation Process Needing time to learn (Executing) “ But I just, you need a little bit of time…for you to figure out how is this going? How are you going to work this into your practice? I don't think—It didn't come naturally for me. I needed to kind of think about it. How am I going to kind of work this in? And that I guess I do see it being a useful in particular summary table just not quite right now. But I do see it as potentially being something that I would use to summarize.” Using a champion and using as a team (Engaging) : “ And again we did have the help of [a champion], I’ll give [them] a lot of credit because we’re all sort of inundated…so to work on it as a team sort of took the onus off one person sort of because we’re working on it together so I think that was another reason why we thought it was doable.” (Insert Table 4 around here – currently at the end of the document) Characteristics of HCPs’ clients (Outer Setting) Participants described client characteristics that would hinder and/or trigger use of the LwR:DSA to meet the needs of their clients . These barriers and facilitators are described below. Barrier . Clients with complex medical needs were described as client-level barriers, as participants were often uncertain about when the LwR:DSA should be used. Brief or one-time encounters, as well as involvement that occurred too early in the care process, were additional client-related factors that made initiating use of the LwR:DSA more difficult. In contrast, situations characterized by greater certainty, such as independent clients with no obvious safety concerns, clients already known to the HCP, or clients with strong support systems, were viewed as scenarios where the LwR:DSA was not needed. Facilitator . Clients who were older than 65 years of age with multi-modal complexity (i.e. physical, social, cognitive and/or medical concerns) but medically stable, had limited support, or had new concerns were considered good candidates for the LwR:DSA. HCPs also found using the LwR:DSA helpful when there was uncertainty about the situation, or disagreements about concerns and/or recommendations. Additionally, participants found the LwR:DSA helpful with community-dwelling clients and when follow-up visits were possible. Both a Facilitator and a Barrier . Perceived safety concerns and clients with cognitive impairment functioned as both barriers and facilitators to LwR:DSA adoption. Multiple or complex safety concerns prompted some HCPs to use the LwR:DSA, but for others these same concerns complicated prioritization and increased the time required for completion. Cognitive impairment was viewed as a barrier when reduced insight, judgment, or abstract thinking limited clients’ ability to participate in shared decision-making. Conversely, perceived cognitive limitations motivated some HCPs to apply the LwR:DSA more intentionally due to the heightened risk for negative outcomes. Caregiver involvement similarly exerted bidirectional effects, facilitating meaningful discussions for some participants, while others felt caregiver support reduced the perceived urgency of safety concerns, thereby diminishing perceived need to use the LwR:DSA. Characteristics of Hospital and Community Practice Settings (Inner Setting) Aspects of participants’ environments acted as both barriers and facilitators to adopting the LwR:DSA. Barrier . Inconvenient a ccess to resources was seen as a barrier to using the LwR:DSA in practice for participants who had difficulty keeping track of where to access the implementation strategies of the LwR:DSA (training videos, instruction guide, worksheets). Facilitator . Strong networks and communication processes were identified as facilitators by participants working within collaborative, supportive, proactive, and well-functioning teams. A positive learning climate was identified as a facilitator by those participants given time for self-reflection. Engaged leadership further facilitated adoption. Unexpectedly, disengaged leadership (leaders with large portfolios and minimal involvement) also functioned as a facilitator for some as it allowed greater autonomy and freedom to use the LwR:DSA in practice. Both a Facilitator and a Barrier . Organizational culture of participants’ practice setting were both a facilitator and barrier. Cultures that valued innovation, prioritized improving the client experience, engaged in research, or strived for excellence were experienced as highly supportive of trying the LwR:DSA. Client-centred cultures that were tolerant of risk similarly facilitated use. Conversely, risk-averse cultures created barriers. For example, one participant noted concern that a risk-averse hospital would not support staff in the event of litigation related to LwR:DSA-guided decisions. Compatibility facilitated use for participants who had autonomy in their practice, were able to integrate the LwR:DSA into existing workflows (e.g., care conferences, assessments), or could align it with existing team processes such as orientation. For others, compatibility acted as a barrier when practitioners were unsure how to incorporate the tool into existing documentation requirements or found that using it added extra time. One participant noted that embedding the LwR:DSA into their electronic medical record would enhance compatibility and ease of use. Changes to the healthcare system during the pandemic increased some clients’ risk for adverse events, which elevated the relative priority of the LwR:DSA and facilitated its use. However, competing priorities, such as shifting to virtual care conferences or changes in clientele, lowered its priority for others, especially when they already had established processes for assessing and managing risk. Tension for change was a facilitator for participants who were searching for a better way of providing client-centered risk assessment but a barrier for those who were satisfied with their current practice. Available resources was a facilitator for participants who used the LwR:DSA as a team but a barrier if there was not team buy-in. Participants described that using the LwR:DSA as a team promoted a common understanding and shared language which facilitated everyone being on the same page. However, lack of team buy-in, alongside broader constraints such as high workload, insufficient staffing, and HCP burnout, were described as significant barriers to implementing the LwR:DSA as a team-based process. Characteristics related to the LwR:DSA (Innovation) Participants described characteristics of the LwR:DSA that served as both barriers and facilitators to using it in practice. Facilitator . Most participants viewed the LwR:DSA’s evidence strength and quality and “low cost ” as facilitators to using it in practice. Both a facilitator and a barrier . The LwR:DSA’s relative advantage was considered by participants as being both a barrier and facilitator to adoption. Relative advantage was noted as a barrier by the participants who felt that it did not provide more value than current practice and a facilitator by those who experienced the benefits of using the LwR:DSA. Participants who found the LwR:DSA beneficial, described the LwR:DSA as useful, effective and applicable for a diversity of clients and clinical contexts. They valued its systematic and comprehensive structure and the way it formalized existing approaches to risk assessment. The adaptability of the LwR:DSA was a facilitator for participants who were able to adapt the LwR:DSA to their clinical processes but a barrier for the participants who felt its adaptability would hinder their team’s ability to know how to use it. Other participants indicated that the recommendations to reduce risk were only a small part of their overall recommendations to the client and therefore not adaptable to their full scope of practice. The LwR:DSA’s complexity was a facilitator for those participants who described the LwR:DSA as simple, comprehensive, clear, concise, succinct, intuitive and easy to use, but a barrier for those who considered it complicated, overwhelming, time-consuming, confusing and repetitive. The professional design and overall quality of the LwR:DSA facilitated use for most participants. However, two participants identified the lack of a digitized version of the worksheets as a barrier, noting challenges with sharing summaries electronically with clients and caregivers or uploading them into electronic medical records. Characteristics related to the HCPs (Individuals) Both a Facilitator and a Barrier . Participant characteristics acted as both facilitators and barriers to using the LwR:DSA in practice. Existing knowledge of the LwR:DSA or a strong interest in risk assessment facilitated adoption for some participants. At the same time, limited experience with risk (i.e. new to the role or a recent graduate) also motivated some HCPs to use the LwR:DSA as a structured guide. Conversely, established knowledge and approaches to risk assessment and management created a barrier for participants who felt the LwR:DSA did not align with their usual practice. Several participants also described simply “forgetting” to use the LwR:DSA, highlighting another barrier. Other personal attributes emerged from the data that were both facilitators and barriers to using the LwR:DSA in practice. Knowledge of topics helpful for learning about the LwR:DSA (i.e. the PIECES framework, motivational interviewing), having a commitment to client choice, or using a biopsychosocial lens were considered facilitators. Participants who described themselves as proactive, systematic, improvement-oriented, or motivated to support the study’s goals also reported that these attributes enhanced their ability to integrate the LwR:DSA. In contrast, personal attributes that limited use included feeling comfortable with current practice, reluctance to be guided by a structured tool, or a desire to “figure out” risk assessment independently before adopting a new approach. Characteristics related to the Implementation Process (Implementation Process) . Participants highlighted elements of the implementation process that were both barriers and facilitators to using the LwR:DSA. Facilitator . Having an internal champion to support the LwR:DSA in practice was considered a facilitator for engaging in implementation. Champions supported engagement by helping participants learn how to integrate the LwR:DSA into practice and by serving as accessible problem-solvers during early use. Both a Facilitator and a Barrier . Time was a central factor during implementation process. Having dedicated time to learn and practice using the LwR:DSA facilitated adoption, whereas limited time created a barrier. Implementing the tool as a team further supported adoption by enabling shared learning, consistent use, and collective problem-solving; however, when team involvement was not possible, this limited the ease of implementation. Discussion To inform broader implementation of the LwR:DSA, this study sought to identify multi-level determinants of adoption using the CFIR’s five domains. We first characterized the level of LwR:DSA adoption among multidisciplinary hospital- and community-based HCPs, followed by an examination of the barriers and facilitators they encountered while preparing for use and adopting the LwR:DSA for eight weeks. Interpreting these determinants alongside the observed adoption level provides important insight into the conditions that supported or constrained LwR:DSA adoption and clarifies the types of implementation supports that may be required for sustained integration. Understood together, this integrated view of adoption levels and determinants provides a foundation for tailoring implementation strategies that can strengthen and sustain LwR:DSA use in real-world practice. Adoption was defined as the number of clients with whom participants used the LwR:DSA and was measured through self-report. A high proportion (80%) of participants adopted the LwR:DSA at least once over the eight-week period. Although successful uptake has been described as a greater than 50% increase in intervention use [ 38 ], high adoption rates remain uncommon. For example, decision support tools typically demonstrate adoption rates ranging from 3%–28% [ 39 – 41 ]. Across CFIR’s 39 constructs, participants identified 19 facilitators and 14 barriers to LwR:DSA adoption, across all five CFIR domains. Thirteen constructs functioned as both barriers and facilitators, suggesting that their influence on adoption was contextual, dynamic, and often nuanced. The greater number of facilitators aligns with the high adoption rate observed. Conversely, the identified barriers may reflect determinants that negatively influence adherence or sustained use rather than initial uptake alone. Taken together, distinguishing which barriers require targeted strategies and which facilitators can be leveraged, provides essential guidance for supporting future implementation and sustainability of the LwR:DSA specifically and more broadly decision support tools in healthcare settings. The results of this study highlighted with whom (Outer Setting) the LwR:DSA’s use was perceived to be most helpful in meeting clients’ needs. Client situations of uncertainty driven by multiple or new concerns, cognitive impairment, lack of support or complexity appeared to increase the perceived value of adopting the LwR:DSA. Additionally, the LwR:DSA was found to help navigate disagreements about care plans and/or next steps between HCPs within the team, between the HCP and the client, or between the client and their caregiver. These reasons for use are consistent with those identified in the earlier LwR:DSA validation and adaptation study [ 10 ], while offering additional contextual detail in how social and relational dynamics influence use. Caregiver involvement emerged as a particularly nuanced determinant. For some participants, the presence of an engaged caregiver facilitated use of the LwR:DSA by enabling shared understanding and collaborative risk management. In contrast, other participants perceived caregiver involvement as reducing overall risk, which in turn diminished the perceived need to use the LwR:DSA. This interpretation suggests that caregiver presence may be conflated with risk resolution rather than recognized as an opportunity to engage in structured shared decision-making. A similar tension was observed in relation to cognitive impairment, while some HCPs viewed shared decision-making as infeasible in this context, a perception noted in prior research [ 42 ], others have emphasized the importance of involving people living with dementia and their caregivers in risk communication particularly given the quality of life implications of risk mitigation strategies [ 43 ]. It is critical therefore, to specifically address potential adoption issues among HCPs who assume that people with cognitive impairments are not able to participate in risk assessment. This is particularly important as people with cognitive impairment and their family caregivers may be a key group to assist in risk management through the use of the LwR:DSA. Compatibility was a prominent Inner Setting construct influencing HCPs’ ability to adopt the LwR:DSA. Participants described fitting the LwR:DSA into their existing practice as a key facilitator, whereas the added time required to use the LwR:DSA was the primary barrier. Lack of time is a consistent theme across implementation studies [ 44 ], including those focused on shared decision-making [ 45 , 46 ]. More specifically, insufficient time to learn new methods [ 47 ], the need for protected implementation time [ 48 ], and the time demands of education and mentoring [ 24 ] were all also identified in this study as time barriers. This perceived time burden may also reflect challenges aligning the LwR:DSA with current workflows. The broader implementation literature also emphasized the importance of integrating innovations into existing workflows, particularly for shared decision-making [ 31 , 33 , 47 , 49 ] and clinical decision support tools [ 24 ]. Since implementing any innovation inevitably requires additional time, understanding how to integrate the LwR:DSA into existing practices and workflows could help leverage this facilitator while also reducing the perceived barrier of increased time and workload. Findings suggested that team-based adoption of the LwR:DSA functioned as an Inner Setting facilitator, particularly by addressing resource constraints and risk aversion. Rather than merely increasing participation, collective team use appeared to redistribute the cognitive and relational workload associated with adopting an innovation, thereby enhancing perceived feasibility and sustainability. Shared adoption of the LwR:DSA may also have strengthened collective efficacy by promoting a common language, aligning risk thresholds and normalizing shared accountability for complex decisions. Findings align with broader implementation research demonstrating that interprofessional collaboration, team buy-in, and whole-team training facilitate adoption of shared decision-making and decision support tools [ 44 , 45 , 50 ] and supports evidence that implementation is more likely to be sustained when change is enacted at the team rather than the individual level [ 51 , 52 ]. Although participants engaged in the study as individuals rather than as part of an organizational initiative, leadership support still emerged as an Inner Setting facilitator, reinforcing leadership engagement as a core component of implementation readiness [ 19 ]. This finding is consistent with literature emphasizing leadership support [ 24 , 26 , 32 , 33 , 45 , 47 , 48 , 53 ] and leader encouragement [ 31 , 53 ] as important facilitators. Interestingly, some participants also described disengaged leadership as a facilitator, suggesting that autonomy in clinical decision-making may support initial use of the LwR:DSA. Perceived complexity of the LwR:DSA (Innovation) functioned as both a barrier and facilitator to adoption. Some participants found the LwR:DSA straight forward, intuitive and easy to use while others described it as confusing, complicated, and overwhelming. In the previous validation and adaptation study, worksheets were developed at the request of HCPs to operationalize the LwR:DSA [ 10 ]. However, in the present study, the number of worksheets may have contributed to perceptions of complexity. Although tools and worksheets are recognized facilitators of implementing decision support tools [ 24 ] and shared decision-making [ 26 ], they must remain simple and user-friendly to avoid competing with existing priorities and workflow demands [ 50 ]. The HCP’s (Individual) knowledge of the LwR:DSA, risk and their experience in risk assessment was both a barrier and facilitator to adoption which is consistent with existing literature. Having the knowledge and experience in using a tool was seen as a facilitator for implementation of a decision support tool for decisional capacity assessment [ 48 ] and practicing foundational concepts such as person-centred care was a facilitator for shared decision-making [ 32 ] and the LwR:DSA. However, experience can also be a barrier to adoption if HCPs feel that they do this skill already [ 26 ] which was highlighted by some participants in this study. Having time to learn and practice the LwR:DSA (Implementation Process) facilitated successful LwR:DSA adoption and is substantiated in the literature [ 24 , 33 , 46 – 48 , 53 ]. Participants of this study also indicated that having a champion would facilitate use by promoting the innovation, demonstrating how it could be integrated into practice, answering questions about, reminding to use and supporting how to use. These functions of a champion align closely with prior studies demonstrating the value of champions in implementing both shared decision-making and decision support tools [ 24 , 31 , 32 , 46 – 48 , 53 ]. Additionally, using champions can have an additive effect by reinforcing and sustaining new learning related to the innovation. Strengths This study has several strengths that enhance the credibility, rigor and practical usefulness of the findings. First, using a well-established determinants framework represents a key strength. Applying the CFIR enabled a comprehensive, multi-level exploration of determinants, particularly because participants did not spontaneously reflect on determinants across all five domains. Notably, all participants required structured probing to elicit individual-level influences on adoption which many did not initially recognize as shaping their implementation decisions. A second strength was recruiting participants who used the LwR:DSA within their own clinical practice. This pragmatic approach generated rich, high-quality data about adoption, an important consideration when prioritizing depth and information power over traditional notions of data saturation [ 54 ]. Studying determinants under real-world conditions provided meaningful insights into a practical clinical problem. By mirroring how HCPs might practically encounter the LwR:DSA following a presentation allowed for realistic observations of early adoption processes. Similarly, instructing HCPs to integrate the tool into their usual care offered an authentic view of determinants operating under typical conditions, including the complexity and resource constraints commonly described by HCPs working with older adults [ 55 , 56 ] and those conducting risk assessments [ 57 ]. The rigor of the qualitative data was further supported through strategies that enhanced authenticity and credibility [ 58 , 59 ]. For instance, creating space for open dialogue and using a data-driven coding approach to ensure participants’ perspectives were accurately represented. Together, these strategies strengthened confidence in the trustworthiness and applicability of the findings. Limitations Although this study offers important insights into the adoption of the LwR:DSA, several limitations should be considered when interpreting the findings. First, the high adoption rate limits the generalizability of the findings to a general population of HCPs as the participants had a high interest in risk, worked within innovative cultures, had positive relationships with colleagues and leaders, were experienced (10 + years) and were able to take part in a study over eight weeks during a time of competing priorities (related to a pandemic). This type of proactive personality has been associated with innovative work behaviour [ 60 ], increased adoption [ 61 ], and ability to scan for and create opportunities during times of uncertainty such as the recent pandemic [ 62 ]. As such, barriers identified by these participants may warrant greater weight for generalizability than the facilitators they described. Second, adoption was self-reported and some participants were known to the lead researcher (from participation in a previous study of the LwR:DSA or were previous colleagues) which may have introduced social desirability bias [ 63 ]. While this possibility cannot be excluded, several factors increase confidence in the accuracy of the reported adoption rates: participants submitted completed worksheets and study logs, two HCPs openly reported not using the LwR:DSA during the eight weeks, and most participants acknowledged they could have used the tool more frequently. These elements provided a degree of accountability and suggest that reported adoption was not uniformly inflated. Finally, it is possible that eight weeks of use was not sufficient time to learn a new approach to care and integrate into practice. However, many studies elicit anticipated barriers and facilitators from knowledge users without implementation [ 64 , 65 ]. Given that the data were collected following use of the LwR:DSA, the data presented in this chapter are actual barriers and facilitators, and another strength of the study. Implications for Practice and Research Our findings support ongoing efforts to integrate the LwR:DSA into routine practice. Understanding the barriers and facilitators to adoption is essential for selecting and tailoring implementation strategies that address modifiable challenges while leveraging existing strengths. As determinants were identified across all five CFIR domains (Outer Setting, Inner Setting, Innovation, Characteristics of Individuals, and Implementation Process), future implementation efforts will require multi-level strategies . For instance, an implementation guide could outline with whom the LwR:DSA is most appropriate to use (Outer Setting), and include discussion of situations where an HCP may hesitate to use it (e.g., patient with cognitive impairment or is viewed as having strong family support), how it can be integrated into existing workflows (Inner Setting), and which processes best support implementation, such as designating champions and using the LwR:DSA as a team (Implementation Process). Simplifying aspects of the LwR:DSA may also help reduce perceived complexity (Innovation). Introducing a “coaching conversations” worksheet may support the types of discussions already occurring in clinical practice, while additional training modules could enhance HCPs’ foundational knowledge and skills (Characteristics of Individuals). Highlighting the importance of establishing favourable conditions for adoption, such as supportive relationships, an innovative culture, and a positive learning climate, may further strengthen readiness for implementation. Future research should focus on monitoring knowledge use and evaluating outcomes (e.g. improved client engagement, improved clinical thinking, decision-making and communication, decreased moral distress and improved team processes) of using the LwR:DSA [ 18 ]. Also, as the LwR:DSA has predominantly only been studied with HCPs, future research should focus on the older adult’s perspective of the LwR:DSA and whether this approach supports their decisional needs. Conclusions Risk assessment and management remains a highly relevant clinical challenge, as current practice often defaults to over-protective approaches that may unintentionally cause harm. The LwR:DSA offers a more balanced, systematic, and person-centred method for identifying and managing risk. This study provides important insights into the determinants influencing its adoption in real-world clinical settings. Findings highlight the need to target modifiable determinants across multiple domains, including clarifying contexts for use, supporting integration into existing workflows, and strengthening team-based adoption through leadership engagement and champion support. Importantly, the LwR:DSA may represent a scalable, low-cost systems intervention capable of supporting quality and safety objectives while preserving person-centred care. Although lack of time is frequently cited as a barrier, system-level strategies, including embedding the LwR:DSA within documentation systems and clinical pathways, allocating protected time for training, and fostering organizational cultures that value balanced approaches to risk, can create the conditions necessary for successful adoption. These findings underscore that implementation of the LwR:DSA should not be viewed solely as an individual HCP responsibility but as an organizational and policy priority aligned with improving quality of care, supporting autonomy, and strengthening shared decision-making for older adults. Abbreviations CFIR Consolidated Framework for Implementation Research COREQ Consolidated Criteria for Reporting Qualitative Research (COREQ) HCPs Healthcare Professionals LwR:DSA Living with Risk: Decision Support Approach OT Occupational Therapist PT Physiotherapist RN Registered Nurse SW Social Worker Declarations Ethics approval and consent to participate This study obtained ethics approval from Queen’s University Health Sciences & Affiliated Teaching Hospitals Research Ethics Board (REH-815-21). All methods were carried out in accordance with this institutional ethics review board’s guidelines and regulations. Informed consent was obtained from all participants in advance of data collection. Consent for publication Not applicable Competing Interests The authors declare that they have no competing interests Funding This study obtained financial support from the Canadian Institutes of Health Research’s Knowledge Translation Catalyst Grant: Quadruple Aim and Equity (475339) In-kind donations were provided by CIUSS de l’Estrie-CHUS, Users’ Committee for the CHUS, Research Centre on Aging (Université de Sherbrooke), Université de Sherbrooke, Regroupement des unités de courte durée gériatriques et des services hospitaliers gériatriques du Québec, and Regional Geriatric Program of Eastern Ontario. None of the financial or in-kind funders had any role in the study design, data collection, analysis, data interpretation or writing the manuscript. Author Contribution HM, DK, KBL and VP contributed to the conception of study, study design, interpretation of data, and co-creation of draft manuscript. NDC, ME, NV, DG, MJL and JK collaborated to the data interpretation and revised the draft manuscript. All authors have reviewed and approved the submitted version of the manuscript. Acknowledgement The authors would like to thank the health care professionals who took part in this study during a time of uncertainty, increased workload and competing priorities related to the COVID-19 pandemic. The authors would also like to thank the research assistant involved in this project, namely Monia D’Amours. HM would like to thank her doctoral defence committee Kathryn Sibley, Jennifer Tomasone and Catherine Donnelly for their invaluable input. Data Availability The data generated and analysed during the current study are available from the corresponding author on reasonable request. References Felton A, Wright N, Stacey G. Therapeutic risk-taking: A justifiable choice. Br J Psychol Adv. 2017;23(2):81–8. 10.1192/apt.bp.115.015701 . Slovic P, Peters E. Risk perception and affect. Curr Dir Psychol Sci. 2006;15(6):322–5. 10.1111/j.1467-8721.2006.00461.x . Durocher E, Kinsella EA. Ethical tensions in occupational therapy practice: Conflicts and competing allegiances. Can J Occup Ther. 2021;88(3):244–53. 10.1177/00084174211021707 . Moats G. Discharge decision-making, enabling occupations, and client-centred practice. Can J Occup Ther. 2007;74(2):91–101. 10.1177/000841740707400203 . Désormeaux-Moreau M, Aubin G, Larivière N, SÉCuRE. A clinical tool for comprehensively assessing home safety of people with mental illness. Br J Occup Ther. 2018;81(9):503–13. 10.1177/0308022618762085 . Lee L, Hillier LM, Lu SK, Martin SD, Pritchard S, Janzen J, Slonim K. Person-centered risk assessment framework: assessing and managing risk in older adults living with dementia. Neurodegener Dis Manag. 2019;9(1):47–57. 10.2217/nmt-2018-0031 . Taylor BJ. Risk-managing decision-making: A psycho-social rationality model. Br J Soc Work. 2021;51(7):2819–38. 10.1177/1471301217704119 . Titterton M. Risk and risk taking in health and social welfare. London: Jessica Kingsley; 2005. MacLeod H, Stadnyk R, Risk. I know it when I see it: how health and social practitioners defined and evaluated living at risk among community-dwelling older adults. Health Risk Soc. 2015;17(1):46–63. 10.1080/13698575.2014.999749 . MacLeod H, Veillette N, Klein J, Delli-Colli N, Egan M, Giroux D, et al. Shifting the narrative from living at risk to living with risk: validating and pilot-testing a clinical decision support tool: a mixed methods study. BMC Geriatr. 2023;23(1):1–14. 10.1186/s12877-023-04068-w . Proctor E, Ramsey AT, Saldana L, Maddox TM, Chambers DA, Brownson RC. FAST: a framework to assess speed of translation of health innovations to practice and policy. Glob Implement Res Appl. 2022;2(2):107–19. 10.1007/s43477-022-00045-4 . Brownson RC, Colditz GA, Proctor EK, editors. Dissemination and Implementation Research in Health: Translating Science to Practice. 2nd ed. Oxford: Oxford University Press; 2018. 10.1093/oso/9780190683214.001.0001 . Eccles M, Mittman B. Welcome to Implementation Science. Implement Sci. 2006;1(1):1. 10.1186/1748-5908-1-1 . Bauer M, Damschroder L, Hagedorn H, Smith J, Kilbourne A. An introduction to implementation science for the non-specialist. BMC Psychol. 2015;3(1):32. 10.1186/s40359-015-0089-9 . Hughes JM, Zullig LL, Choate AL, et al. Intensification of Implementation Strategies: Developing a Model of Foundational and Enhanced Implementation Approaches to Support National Adoption and Scale-up. Gerontologist. 2023;63(3):604–13. 10.1093/geront/gnac130 . Kilbourne AM, Smith SN, Choi SY, et al. Adaptive School-based Implementation of CBT (ASIC): clustered-SMART for building an optimized adaptive implementation intervention to improve uptake of mental health interventions in schools. Implement Sci. 2018;13(1):119. 10.1186/s13012-018-0808-8 . Lewis CC, Scott K, Marti CN, et al. Implementing measurement-based care (iMBC) for depression in community mental health: a dynamic cluster randomized trial study protocol. Implement Sci. 2015;10:127. 10.1186/s13012-015-0313-2 . Published 2015 Sep 7. Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, Robinson N. Lost in knowledge translation: Time for a map? J Contin Educ Health Prof. 2006;26(1):13–24. 10.1002/chp.47 . Damschroder L, Aron D, Keith R, Kirsh S, Alexander J, Lowery J. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50. 10.1186/1748-5908-4-50 . Moullin JC, Dickson KS, Stadnick NA, Albers B, Nilsen P, Broder-Fingert S, et al. Ten recommendations for using implementation frameworks in research and practice. Implement Sci Commun. 2020;1:1–12. 10.1186/s43058-020-00023-7 . Waltz T, Powell B, Fernández M, Abadie B, Damschroder L. Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions. Implement Sci. 2019;14(1):42. 10.1186/s13012-019-0892-4 . Leeman J, Birken SA, Powell BJ, Rohweder C, Shea CM. Beyond implementation strategies: classifying the full range of strategies used in implementation science and practice. Implement Sci. 2017;12(1):125. 10.1186/s13012-017-0657-x . Bowles KH, Holland DE, Potashnik SL. Implementation and testing of interdisciplinary decision support tools to standardize discharge planning. NI 2012 (2012). 2012;2012:41. Brémault-Phillips SC, Parmar J, Friesen S, Rogers LG, Pike A, Sluggett B. An evaluation of the decision-making capacity assessment model. Can Geriatr J. 2016;19(3):83. 10.5770/cgj.19.222 . Dobler CC, Sanchez M, Gionfriddo MR, et al. Impact of decision aids used during clinical encounters on clinician outcomes and consultation length: a systematic review. BMJ Qual Saf. 2019;28(6):499–510. 10.1136/bmjqs-2018-008022 . Joseph-Williams N, Lloyd A, Edwards A, Stobbart L, Tomson D, Macphail S, et al. Implementing shared decision making in the NHS: lessons from the MAGIC programme. BMJ. 2017;357:j1744. 10.1136/bmj.j1744 . Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci. 2016;11:72. 10.1186/s13012-016-0437-z . Published 2016 May 17. Mertz E, Wides C, White J. Clinician attitudes, skills, motivations and experience following the implementation of clinical decision support tools in a large dental practice. J Evid Based Dent Pract. 2017;17(1):1–12. 10.1016/j.jebdp.2016.10.001 . Osheroff JA, Teich JM, Middleton B, Steen EB, Wright A, Detmer DE. A roadmap for national action on clinical decision support. J Am Med Inf Assoc. 2007;14(2):141–5. 10.1197/jamia.M2334 . Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10:21. 10.1186/s13012-015-0209-1 . Scholl I, LaRussa A, Hahlweg P, Kobrin S, Elwyn G. Organizational- and system-level characteristics that influence implementation of shared decision-making and strategies to address them—a scoping review. Implement Sci. 2018;13(1):1–22. 10.1186/s13012-018-0731-z . Schön UK, Grim K, Wallin L, Rosenberg D, Svedberg P. Psychiatric service staff perceptions of implementing a shared decision-making tool: a process evaluation study. Int J Qual Stud Health Well-being. 2018;13(1):1421352. 10.1080/17482631.2017.1421352 . Tan AS, Mazor KM, McDonald D, Lee SJ, McNeal D, Matlock DD, Glasgow RE. Designing shared decision-making interventions for dissemination and sustainment: can implementation science help translate shared decision making into routine practice? MDM Policy Pract. 2018;3(2):2381468318808503. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38:65–76. 10.1007/s10488-010-0319-7 . Lumivero. NVivo (Version 14) [software]. Denver (CO): Lumivero; 2023. Available from: https://www.lumivero.com Microsoft Corporation. (2024). Microsoft Excel . Retrieved from https://office.microsoft.com/excel Nicmanis M. Reflexive content analysis: An approach to qualitative data analysis, reduction, and description. Int J Qual Methods. 2024;23. 10.1177/16094069241236603 . Levine R, Zingelman S, McSween MP, Shrubsole K, Hill AJ, Copland DA. Allied Health Clinicians' Uptake of Evidence in Stroke Rehabilitation: A Systematic Review of Determinants Targeted in Implementation Studies. Arch Phys Med Rehabil. 2024;105(5):988–99. 10.1016/j.apmr.2023.08.018 . Brunner J, Farmer MM, Bean-Mayberry B, et al. Implementing clinical decision support for reducing women Veterans' cardiovascular risk in VA: A mixed-method, longitudinal study of context, adaptation, and uptake. Front Health Serv. 2022;2:946802. 10.3389/frhs.2022.946802 . Purkey E, Bayoumi I, Coo H, et al. Exploratory study of real world implementation of a clinical poverty tool in diverse family medicine and pediatric care settings. Int J Equity Health. 2019;18(1):200. 10.1186/s12939-019-1085-0 . Published 2019 Dec 23. Silvestrin TM, Steenrod AW, Coyne KS, et al. An approach to improve the care of mid-life women through the implementation of a Women's Health Assessment Tool/Clinical Decision Support toolkit. Womens Health (Lond). 2016;12(5):456–64. 10.1177/1745505716664742 . Pel-Littel RE, Snaterse M, Teppich NM, Buurman BM, van Etten-Jamaludin FS, van Weert JC, et al. Barriers and facilitators for shared decision making in older patients with multiple chronic conditions: a systematic review. BMC Geriatr. 2021;21:1–14. 10.1186/s12877-021-02050-y . Stevenson M, Savage B, Taylor BJ. Perception and Communication of Risk in Decision Making by Persons with Dementia. Dement (London). 2019;18(3):1108–27. 10.1177/1471301217704119 . Waddell A, Lennox A, Spassova G, Bragge P. Barriers and facilitators to shared decision-making in hospitals from policy to practice: a systematic review. Implement Sci. 2021;16:1–23. 10.1186/s13012-021-01142-y . Boland L, Lawson ML, Graham ID, Légaré F, Dorrance K, Shephard A, Stacey D. Post-training shared decision making barriers and facilitators for pediatric healthcare providers: A mixed-methods study. Acad Pediatr. 2019;19(1):118–29. 10.1016/j.acap.2018.05.010 . Elwyn G, Scholl I, Tietbohl C, Mann M, Edwards AG, Clay C, et al. Many miles to go…a systematic review of the implementation of patient decision support interventions into routine clinical practice. BMC Med Inform Decis Mak. 2013;13(Suppl 2):S14. doi:10.1186/1472-6947-13-S2-S14. Parmar J, Sacrey LA, Anderson S, Charles L, Dobbs B, McGhan G, et al. Facilitators, barriers and considerations for the implementation of healthcare innovation: a qualitative rapid systematic review. Health Soc Care Community. 2022;30(3):856–68. 10.1111/hsc.13578 . Brémault-Phillips S, Pike A, Charles L, Roduta-Roberts M, Mitra A, Friesen S, et al. Facilitating implementation of the Decision-Making Capacity Assessment (DMCA) Model: senior leadership perspectives on the use of the National Implementation Research Network (NIRN) Model and frameworks. BMC Res Notes. 2018;11:1–10. 10.1186/s13104-018-3714-x . Munro S, Manski R, Donnelly KZ, Agusti D, Stevens G, Banach M, et al. Investigation of factors influencing the implementation of two shared decision-making interventions in contraceptive care: a qualitative interview study among clinical and administrative staff. Implement Sci. 2019;14:1–16. 10.14288/1.0385167 . Joseph-Williams N, Abhyankar P, Boland L, Bravo P, Brenner AT, Brodney S, et al. What works in implementing patient decision aids in routine clinical settings? A rapid realist review and update from the International Patient Decision Aid Standards Collaboration. Med Decis Mak. 2021;41(7):907–37. 10.1177/0272989X20978208 . Harding KE, Porter J, Horne-Thompson A, Donley E, Taylor NF. Not enough time or a low priority? Barriers to evidence-based practice for allied health clinicians. J Contin Educ Health Prof. 2014;34(4):224–31. 10.1002/chp.21255 . McGuier EA, Aarons GA, Byrne KA et al. Associations between teamwork and implementation outcomes in multidisciplinary cross-sector teams implementing a mental health screening and referral protocol. Implement Sci Commun. 2023;4(1):13. Published 2023 Feb 10. 10.1186/s43058-023-00393-8 Mathieson A, Grande G, Luker K. Strategies, facilitators and barriers to implementation of evidence-based practice in community nursing: a systematic mixed-studies review and qualitative synthesis. Prim Health Care Res Dev. 2019;20:e6. 10.1017/S1463423618000488 . Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753–60. 10.1177/1049732315617444 . Brouwers C, Merten H, Willems M, et al. Improving care for older patients in the acute setting: a qualitative study with healthcare providers. Neth J Med. 2017;75(8):335–43. Ploeg J, Yous ML, Fraser K, et al. Healthcare providers' experiences in supporting community-living older adults to manage multiple chronic conditions: a qualitative study. BMC Geriatr. 2019;19(1):316. 10.1186/s12877-019-1345-2 . Kemshall H. Bias and error in risk assessment and management. HM Inspectorate Probat Acad Insights. 2021;14. Creswell JW, Creswell JD. Qualitative methods. Research Design: Qualitative, Quantitative and Mixed Methods Approaches. Thousand Oaks (CA): Sage Publications Inc; 2018. pp. 179–211. Milne J, Oberle K. Enhancing rigor in qualitative description. J Wound Ostomy Cont Nurs. 2005;32(6):413–20. 10.1097/00152192-200511000-00014 . Mubarak N, Khan J, Yasmin R, Osmadi A. The impact of a proactive personality on innovative work behavior: the role of work engagement and transformational leadership. Leadersh Organ Dev J. 2021;42(7):989–1003. 10.1108/LODJ-11-2020-0518 . Kandah A, Ehrhart M, Sklar M, Aarons G, Implementation in Health. Who is going to implement? [conference presentation]. 17th Annual Conference on the Science of Dissemination and ; 2024 Dec 8–11; Arlington, VA: Academy Health. Available from: https://academyhealth.org/events/2024-12/17th-annual-conference-science-dissemination-and-implementation Yi-Feng Chen N, Crant JM, Wang N, Kou Y, Qin Y, Yu J, Sun R. When there is a will there is a way: the role of proactive personality in combating COVID-19. J Appl Psychol. 2021;106(2):199. 10.1037/apl0000865 . Bispo Júnior JP. Social desirability bias in qualitative health research. Rev Saude Publica. 2022;56:101. 10.11606/s1518-8787.2022056004164 . Dolansky MA, Pohnert A, Ball S, McCormack M, Hughes R, Pino L. Pre-implementation of the age-friendly health systems evidence-based 4Ms framework in a multi-state convenient care practice. Worldviews Evid Based Nurs. 2021;18(2):118–28. 10.1111/wvn.12498 . Harry ML, Truitt AR, Saman DM, Henzler-Buckingham HA, Allen CI, Walton KM, et al. Barriers and facilitators to implementing cancer prevention clinical decision support in primary care: a qualitative study. BMC Health Serv Res. 2019;19:1–13. 10.1186/s12913-019-4326-4 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8865683","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":591878155,"identity":"5019b081-903f-43a8-9397-4f11866bf03d","order_by":0,"name":"Heather MacLeod","email":"data:image/png;base64,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","orcid":"","institution":"Provincial Geriatrics Leadership Ontario","correspondingAuthor":true,"prefix":"","firstName":"Heather","middleName":"","lastName":"MacLeod","suffix":""},{"id":591878156,"identity":"ee70ddef-7f18-4c58-8f59-d629491ac97d","order_by":1,"name":"Véronique Provencher","email":"","orcid":"","institution":"Université de Sherbrooke","correspondingAuthor":false,"prefix":"","firstName":"Véronique","middleName":"","lastName":"Provencher","suffix":""},{"id":591878157,"identity":"655896dc-589e-440c-977c-27d0220c750d","order_by":2,"name":"Nathalie Veillette","email":"","orcid":"","institution":"Université de Montréal","correspondingAuthor":false,"prefix":"","firstName":"Nathalie","middleName":"","lastName":"Veillette","suffix":""},{"id":591878158,"identity":"3e99636d-4678-4cb3-8086-4c44d184d3df","order_by":3,"name":"Jennifer Klein","email":"","orcid":"","institution":"Glenrose Rehabilitation Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Klein","suffix":""},{"id":591878159,"identity":"0cac6305-8b57-4ae2-9238-72ca6e837df7","order_by":4,"name":"Nathalie Delli-Colli","email":"","orcid":"","institution":"Université de Sherbrooke","correspondingAuthor":false,"prefix":"","firstName":"Nathalie","middleName":"","lastName":"Delli-Colli","suffix":""},{"id":591878160,"identity":"06830162-bd40-41ee-a0dd-2d6648b097b9","order_by":5,"name":"Mary Egan","email":"","orcid":"","institution":"University of Ottawa","correspondingAuthor":false,"prefix":"","firstName":"Mary","middleName":"","lastName":"Egan","suffix":""},{"id":591878161,"identity":"7c903d54-5d27-4e84-8cad-7ead5573807d","order_by":6,"name":"Dominique Giroux","email":"","orcid":"","institution":"Université Laval","correspondingAuthor":false,"prefix":"","firstName":"Dominique","middleName":"","lastName":"Giroux","suffix":""},{"id":591878162,"identity":"d8a3c6c8-5f8e-4518-be04-a22e1946d5c4","order_by":7,"name":"Marie-Jeanne Kergoat","email":"","orcid":"","institution":"Institut Universitaire de Gériatrie de Montréal Research Center","correspondingAuthor":false,"prefix":"","firstName":"Marie-Jeanne","middleName":"","lastName":"Kergoat","suffix":""},{"id":591878165,"identity":"5603a920-bc29-443d-8845-c4cf95bb1719","order_by":8,"name":"Krystina B. Lewis","email":"","orcid":"","institution":"University of Ottawa","correspondingAuthor":false,"prefix":"","firstName":"Krystina","middleName":"B.","lastName":"Lewis","suffix":""},{"id":591878167,"identity":"8c760dae-57ed-445a-a938-f706ce17bade","order_by":9,"name":"Dorothy Kessler","email":"","orcid":"","institution":"Queen’s University","correspondingAuthor":false,"prefix":"","firstName":"Dorothy","middleName":"","lastName":"Kessler","suffix":""}],"badges":[],"createdAt":"2026-02-12 21:23:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8865683/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8865683/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103504715,"identity":"8f8a02ce-c9e1-434d-a5bc-53bdf63130c8","added_by":"auto","created_at":"2026-02-26 13:21:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1591309,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8865683/v1/9d20bba0-8404-495c-86e9-99ca982e8836.pdf"},{"id":103072611,"identity":"bb3b1226-1312-4fd2-9c9f-0a600ab9147a","added_by":"auto","created_at":"2026-02-20 12:41:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":385209,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalFile.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8865683/v1/01f3999a8708e47f301c1664.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers and Facilitators to Adopting a Risk Assessment and Management Decision Support Approach For Safety Concerns of Older Adults: a Multimethods Study","fulltext":[{"header":"Background","content":"\u003cp\u003eIllness, injuries and/or disabilities put older adults at increased risk for adverse outcomes and potential safety concerns as they strive to age in place. Healthcare professionals (HCPs) often attempt to prevent harm for older adults. In doing so, they often overestimate risk and focus on extreme harm [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and use a quick \u0026lsquo;gut reaction\u0026rsquo; approach to evaluating risk [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is not surprising that HCPs are reluctant to support older adults to remain at home if they perceive risks as only negative. This reluctance can lead to moral distress for HCPs [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and older adults feeling coerced to accept undesirable discharge plans (i.e. discharge destinations other than home) when they do not align with their preferences and goals of care [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrent risk assessment and management guidance are focused on specific patient populations (e.g. people with mental health diagnoses [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]), risky activities (e.g. potential for fires while cooking [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]) or provide general theoretical overviews [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These frameworks lack a comprehensive, systematic or practical approach to risk assessment and management that optimizes an older adult\u0026rsquo;s safety, autonomy and resilience. The Living with Risk: Decision Support Approach (LwR:DSA) was developed to address this clinical gap by broadening and balancing HCPs\u0026rsquo; approach to risk assessment to be more supportive of older adults\u0026rsquo; preferences and goals of remaining at home [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe LwR:DSA was developed based on best practices in the community [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], subsequently adapted for hospital contexts and validated in both hospital and community settings [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In practice, the LwR:DSA guides HCPs in collaboration with older adults, to clarify the safety concern and identify its causes, context, and consequences. HCPs are encouraged to consider both the benefits and negative consequences of potential decisions from the perspectives of the older adult, their caregivers, and the healthcare team. These considerations inform the co-creation of solutions to reduce the older adult\u0026rsquo;s risk for negative outcomes while acknowledging the emotional, social, and physical benefits of decisions that may appear risky from the HCPs point of view. In these ways, the LwR:DSA is person-centred, involving the older adult throughout the process.\u003c/p\u003e \u003cp\u003eImplementing the LwR:DSA in care discussions has the potential to promote more intentional, comprehensive, and balanced conversations among HCPs, older adults, and caregivers about potential risks in different living settings. However, adopting new practices into healthcare can be delayed [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], not sustained [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], or only partially adopted [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] when contextual factors influencing uptake are not adequately addressed [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Emerging implementation research suggests that non-tailored, low intensity \u0026lsquo;starter\u0026rsquo; implementation strategies may be used to support initial uptake, with more intensive tailoring occurring downstream as barriers and facilitators are better understood [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Understanding the multi-level determinants of adoption therefore remains a critical step in moving evidence into practice prior to evaluating outcomes as it informs the refinement and tailoring of context-specific implementation strategies [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe aims of this study were to (1) describe the adoption of the LwR:DSA in the hospital and community settings following the use of pre-selected implementation strategies and (2) identify and understand the multi-level determinants (barriers and facilitators) influencing its adoption into practice to inform the refinement, tailoring or development of implementation strategies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis multimethod implementation study gathered quantitative and qualitative data over three phases. The Consolidated Framework for Implementation Research 1.0 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] was selected to determine the barriers and facilitators of adoption as using a theoretical framework ensures a shared language for the generalizability of the findings [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The CFIR was chosen as it comprehensively highlights multi-level factors that typically influence implementation based on the synthesis of 19 implementation models [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. More specifically, 39 constructs are grouped across five domains (Outer Setting, Inner Setting, Innovation, Individual and Implementation Process) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The five domains pertinent to this study were characteristics related to: (1) the HCP participants\u0026rsquo; clients (Outer Setting); (2) the hospital and/or community clinical settings (Inner Setting); (3) the LwR:DSA (Innovation); (4) the multidisciplinary HCPs (Individual); and, (5) the way in which participants adopted the LwR:DSA (Implementation Process).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eWe aimed to recruit a convenience sample of 25\u0026ndash;30 multidisciplinary English- or French-speaking HCPs from across Canada working with older adults in the hospital and community settings over five months (March\u0026ndash;July 2022) using a variety of methods (recruitment emails to professional contacts, and recruitment posters in presentations, organizations\u0026rsquo; newsletters, discussion boards and community of practices). Within networks, individuals were encouraged to forward information to potentially interested participants. HCPs working under supervision (i.e. a provisional license) or currently using the LwR:DSA were excluded. Participants received a \u003cspan\u003e$\u003c/span\u003e25 e-gift card for participating in the individual interview and an additional \u003cspan\u003e$\u003c/span\u003e25 e-gift card if they participated in the focus group. The positionality of the researcher team included that they were clinician-researchers, had experience in qualitative analysis, and some were involved in previous research with the LwR:DSA.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProcedures\u003c/h3\u003e\n\u003cp\u003eThe study took place across three phases (Pre-Use, Use, and Post-Use) between March 2022 and July 2023. Pre-Use: Following informed consent, participants completed a 60-minute virtual training session that overviewed the risk assessment process and the LwR:DSA. Use: Participants then used the LwR:DSA in their clinical practice for eight weeks supported by four pre-selected low-intensity implementation strategies: (1) six, 10-minute brief training videos; (2) an instruction guide; (3) three worksheets; and, (4) bi-monthly researcher initiated emails to provide reminders, clarifications and opportunities to ask questions. These foundational pre-selected strategies were intentionally non-tailored and were designed to support initial adoption by addressing common barriers to new innovations, particularly lack of knowledge and skill [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Strategy selection was also informed from the validation and adaptation of the LwR:DSA [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and by literature on the implementation of decision support tools and shared decision-making interventions [\u003cspan additionalcitationids=\"CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The eight-week time frame was chosen as a reasonable time to (1) learn how to use the LwR:DSA, (2) integrate it into practice, (3) use it several times, while (4) minimizing participant burden. The participants were encouraged to use the LwR:DSA in a way that was most clinically relevant for them. The eight weeks was not continuous to accommodate sick leave and/or vacation time. Post-Use: Participants took part in an individual 60-minute virtual interview within three weeks of completing use.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative\u003c/h2\u003e \u003cp\u003eParticipant demographic quantitative data was obtained via Microsoft Forms during Phase 1 (Pre-Use) when participants registered for the study. The adoption level quantitative data was confirmed with participants during the Phase 3 virtual individual interview (Post-Use). Adoption was defined as participants\u0026rsquo; action of using the LwR:DSA in practice based on the behavioural components of Proctor et al.\u0026rsquo;s [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] definition of adoption. Adoption was determined by participant self-report of the total number of clients with whom they used the LwR:DSA over the eight weeks. Participants recorded weekly on a study log: 1) number of clients with whom they used the LwR:DSA with and 2) number with whom they could have used the LwR:DSA but did not (including the reason for not using it). The self-reported adoption number was supported by submitted study logs, providing partial behavioural verification.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative\u003c/h3\u003e\n\u003cp\u003eQualitative data was gathered during the Phase 3 (Post-Use) virtual individual interview. Interview questions (see Supplementary Files) were 1) adapted from the CFIR Interview Guide (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cfirguide.org/guide/app/#/\u003c/span\u003e\u003cspan address=\"https://cfirguide.org/guide/app/#/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) and then 2) pilot-tested with three HCPs who were familiar with the LwR:DSA but did not participate in the study, with no suggested changes. In the interviews, we sought to elicit barriers and facilitators to adopting the LwR:DSA following its use. Sample questions included \u003cem\u003e\u0026lsquo;what do you perceive were factors that facilitated/were barriers for LwR:DSA use in your clinical context?\u0026rsquo;\u003c/em\u003e, \u003cem\u003e\u0026lsquo;what advantages/disadvantages does the LwR:DSA have compared to current practice?\u0026rsquo;\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eThe first author (HM) conducted virtual 30\u0026ndash;60 min interviews. Notes were taking during and after the interviews. Interviews were audio recorded and transcribed verbatim by a professional transcriptionist. Transcripts were uploaded to NVivo 14 [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] to facilitate coding of the data.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eQuantitative data were analysed using descriptive statistics in Excel [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Qualitative data were analysed by the first author (HM), with 18% of interviews co-coded by a qualitative researcher external to the research team. Any dissonance in coding was discussed for consensus and all coding was reviewed with three members of the research team (DK, VP, KL) for input following the four analytic strategies of reflexive content analysis [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]: (1) transcripts were read for accuracy against the audio recording and then re-read several times to become familiar with the data; (2) data was then inductively coded line by line using codes that represented the words and ideas from participants; (3) codes were reviewed and revised; then (4) organized into an analysis structure of subcategories and then deductively mapped onto the categories (constructs and subconstructs) from the CFIR framework. Additional categories were made for codes/subcategories outside of the CFIR constructs. Researcher reflexivity occurred and was recorded throughout the analysis. As well, analysis was reviewed and validated with 38% of participants in a focus group.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eTwenty-six participants consented to the study. The majority were women (92%), working in the community (54%), with 16\u0026thinsp;+\u0026thinsp;years of experience (61%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Participants represented a variety of disciplines with the majority being occupational therapists (31%) and nurses (27%). One participant withdrew prior to starting the study and contact was lost for three participants (three hospital nurses) despite three email contacts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAdoption\u003c/h2\u003e \u003cp\u003eEighty percent of participants adopted the LwR:DSA with varying frequency over the eight weeks (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Seventy percent of these participants indicated they could have used the LwR:DSA more, with there being no difference across practice settings (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Demographics (N\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunity (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHospital (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e (self-reported)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eDiscipline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eYears of experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e18 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u0026ndash;43 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026ndash;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.5\u0026ndash;43 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eNote.\u003c/em\u003e OT: Occupational Therapist, RN: Registered Nurse, PT: Physiotherapist, SW: Social Worker\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Other includes Nurse Practitioner, Medical Doctor, Recreational Therapist\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eImplementation Outcome: Adoption\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of Adoption\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdopted (range of 1\u0026ndash;16 times over eight weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Adopted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCould have adopted more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown due to Lost contact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eBarriers and Facilitators\u003c/h2\u003e \u003cp\u003eFollowing the 8-week trial period, participants highlighted 20 determinants to using the LwR:DSA in practice across all five CFIR domains (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). While six constructs were identified as being only facilitators and one construct as being only a barrier, 13 constructs were identified as both a barrier and a facilitator. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e provides select quotes per CFIR construct. Barriers and facilitators are discussed next by CFIR Domain and corresponding \u003cem\u003econstructs\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDeterminants (Facilitator vs Barrier) of Adoption by CFIR Domains and Constructs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCFIR Domains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFacilitator Constructs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier\u003c/p\u003e \u003cp\u003eConstructs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBarrier and Facilitator Constructs\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHCPs\u0026rsquo; Clients\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(Outer Setting)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClient Needs \u0026amp; Resources\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital \u0026amp; Community Practice Setting\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(Inner Setting)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNetworks \u0026amp; Communication\u003c/p\u003e \u003cp\u003eLearning Climate\u003c/p\u003e \u003cp\u003eLeadership Engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAccess to Information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCulture\u003c/p\u003e \u003cp\u003eTension for Change\u003c/p\u003e \u003cp\u003eCompatibility\u003c/p\u003e \u003cp\u003eRelative Priority\u003c/p\u003e \u003cp\u003eAvailable Resources\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLwR:DSA\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(Innovation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvidence Strength \u0026amp; Quality\u003c/p\u003e \u003cp\u003eCost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRelative Advantage\u003c/p\u003e \u003cp\u003eAdaptability\u003c/p\u003e \u003cp\u003eComplexity\u003c/p\u003e \u003cp\u003eDesign Quality \u0026amp; Packaging\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHCPs\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(Individual)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnowledge \u0026amp; Beliefs about the Innovation\u003c/p\u003e \u003cp\u003eOther Personal Attributes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProcess of LwR:DSA Adoption\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(Implementation Process)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEngaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExecuting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026lsquo;-\u0026lsquo; indicates no identified construct\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExamples of Barrier and Facilitator Quotes by CFIR Domains\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCFIR Domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBarrier Quote\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitator Quote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristics of the HCPs\u0026rsquo; Clients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eClient known to HCP (client needs and resources)\u003c/b\u003e: \u003cem\u003e\u0026ldquo;[For] some people it just wasn\u0026rsquo;t appropriate or necessary because I had previously known them and was continuing to work with them, and it just wasn\u0026rsquo;t a logical fit\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eClient with risks (client needs and resources)\u003c/b\u003e: \u0026ldquo;\u003cem\u003eIf I was choosing which type of client to complete this with, I feel that I\u0026rsquo;d be more inclined to use it with ones where I anticipated that the risk status was higher or more complicated to help me map out all of the different factors.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristics of the Hospital and Community Practice Setting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTime (Compatibility)\u003c/b\u003e: \u003cem\u003e\u0026ldquo;I guess the burden of workload sort of coincides with time but even if it only takes a few extra minutes per client to add an additional worksheet or additional documentation sometimes just the weight of that extra burden and taking on an extra task regardless of how quantitatively it may not be that much, I feel that healthcare clinicians especially at this point in time, sort of post-pandemic, do not have the capacity to add any extra burden regardless of how much time it actually needs.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eCompeting priorities (Relative Priority)\u003c/b\u003e: \u0026ldquo;\u003cem\u003eI think maybe a reason why I didn\u0026rsquo;t bring it up with the team or used it more formally is because of the pressures that are right now on the system and how burnt out and exhausted people are. I think trying to bring in a brand-new tool and trying to educate everyone on something new when people are already feeling so exhausted, it\u0026rsquo;s maybe not the right time.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCollaborative teams (Networks and Communication)\u003c/b\u003e: \u003cem\u003e\u0026ldquo;I think having like a supportive work environment where you feel you can bring up these concerns, it makes it a little bit easier to have those kinds of discussions.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eInnovative (Culture): \u0026ldquo;\u003c/b\u003e\u003cem\u003eSo I think that generally my work environment is very open to trying new things and seeing how we can best support our patient population. So, in one case, I think overall the work environment is really supportive and interested in innovative ways to address things.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eIntegrating into practice (Compatibility): \u0026ldquo;\u003c/b\u003e\u003cem\u003eWell, I think it wasn\u0026rsquo;t really a big stretch from what I was already doing. So, it was just a different way to frame it. So, it didn\u0026rsquo;t take a lot of extra time, like maybe a bit, to fill out forms and stuff like that but it was something that I\u0026rsquo;m already asking about and I\u0026rsquo;m already considering and so I think that really allowed me to use the tool.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eDissatisfied with current practice (Tension for change\u003c/b\u003e): \u0026ldquo;\u003cem\u003eI was dissatisfied with how I was doing that [risk assessment] previously\u0026hellip;it didn't sit well with me the way I was doing it before\u0026hellip;it wasn't satisfying, I didn't feel like we'd had a good conversation.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristics related to the LwR:DSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eConfusing (Complexity)\u003c/b\u003e: \u003cem\u003e\u0026ldquo;Well I found it a little bit confusing. Trying to figure what is the difference between causes and consequences. That puzzled me sort of...I was always having to go back and review that and like try to make sense of it in my brain. It didn\u0026rsquo;t come to me naturally.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eDesign Quality\u003c/b\u003e: \u0026ldquo;\u003cem\u003eTop notch! On the quality of the documents and worksheets. It was clear. The video too.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eStraight forward (Complexity)\u003c/b\u003e: \u003cem\u003e\u0026ldquo;Oh, I thought they [supporting materials] were really helpful. Yeah, very, very helpful. Very straight forward. Very helpful. In the actual fillable thing is, you know, helpful\u0026hellip;So it's designed nicely. It's easy to read.\u0026hellip; But, yeah, easy to use, straightforward. The materials supporting it were good. All of that, I think is excellent.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eBenefit of using LwR:DSA (Relative advantage)\u003c/b\u003e: \u003cb\u003e\u0026ldquo;\u003c/b\u003e\u003cem\u003eI think because of the frequency of use, for sure, and because I was having outcomes with the tool every time, right? Because I saw the outcome every time I used the tool, I realized it\u0026rsquo;s applicability at that point\u0026hellip;. If I was to use the tool and not get anything out of it, I\u0026rsquo;d be like well I\u0026rsquo;m just using a tool, right? But because I was using a tool and I was still finding a solution; it was more of a reason for me to use it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristics related to the HCPs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eChange is difficult (Other personal attributes)\u003c/b\u003e: \u003cem\u003e\u0026ldquo;And I'm not good at incorporating new things. I'm not good at kind of using standardized tools. My QI colleagues are much better at that. So, it would be an interesting process to think about how to incorporate it more fully, and how to use it more and to remind myself to use it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eLack of knowledge about risk\u003c/b\u003e (\u003cb\u003eKnowledge and belief of LwR:DSA and risk\u003c/b\u003e): \u003cem\u003e\u0026ldquo;This is the type of thing that I think we really need and especially as we\u0026rsquo;re trying to recruit more and more people into healthcare and so having a tool early in your career and getting that mentality early in your career that risk is okay and trying to provide education about risk sooner than later, I think is incredibly beneficial.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristics related to the Implementation Process\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNeeding time to learn (Executing) \u0026ldquo;\u003c/b\u003e\u003cem\u003eBut I just, you need a little bit of time\u0026hellip;for you to figure out how is this going? How are you going to work this into your practice? I don't think\u0026mdash;It didn't come naturally for me. I needed to kind of think about it. How am I going to kind of work this in? And that I guess I do see it being a useful in particular summary table just not quite right now. But I do see it as potentially being something that I would use to summarize.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eUsing a champion and using as a team (Engaging)\u003c/b\u003e: \u0026ldquo;\u003cem\u003eAnd again we did have the help of [a champion], I\u0026rsquo;ll give [them] a lot of credit because we\u0026rsquo;re all sort of inundated\u0026hellip;so to work on it as a team sort of took the onus off one person sort of because we\u0026rsquo;re working on it together so I think that was another reason why we thought it was doable.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e(Insert Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e around here \u0026ndash; currently at the end of the document)\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eCharacteristics of HCPs\u0026rsquo; clients (Outer Setting)\u003c/h2\u003e \u003cp\u003eParticipants described client characteristics that would hinder and/or trigger use of the LwR:DSA to meet the \u003cem\u003eneeds of their clients\u003c/em\u003e. These barriers and facilitators are described below.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBarrier\u003c/b\u003e. Clients with complex medical needs were described as client-level barriers, as participants were often uncertain about when the LwR:DSA should be used. Brief or one-time encounters, as well as involvement that occurred too early in the care process, were additional client-related factors that made initiating use of the LwR:DSA more difficult. In contrast, situations characterized by greater certainty, such as independent clients with no obvious safety concerns, clients already known to the HCP, or clients with strong support systems, were viewed as scenarios where the LwR:DSA was not needed.\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacilitator\u003c/b\u003e. Clients who were older than 65 years of age with multi-modal complexity (i.e. physical, social, cognitive and/or medical concerns) but medically stable, had limited support, or had new concerns were considered good candidates for the LwR:DSA. HCPs also found using the LwR:DSA helpful when there was uncertainty about the situation, or disagreements about concerns and/or recommendations. Additionally, participants found the LwR:DSA helpful with community-dwelling clients and when follow-up visits were possible.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBoth a Facilitator and a Barrier\u003c/b\u003e. Perceived safety concerns and clients with cognitive impairment functioned as both barriers and facilitators to LwR:DSA adoption. Multiple or complex safety concerns prompted some HCPs to use the LwR:DSA, but for others these same concerns complicated prioritization and increased the time required for completion. Cognitive impairment was viewed as a barrier when reduced insight, judgment, or abstract thinking limited clients\u0026rsquo; ability to participate in shared decision-making. Conversely, perceived cognitive limitations motivated some HCPs to apply the LwR:DSA more intentionally due to the heightened risk for negative outcomes. Caregiver involvement similarly exerted bidirectional effects, facilitating meaningful discussions for some participants, while others felt caregiver support reduced the perceived urgency of safety concerns, thereby diminishing perceived need to use the LwR:DSA.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of Hospital and Community Practice Settings (Inner Setting)\u003c/h2\u003e \u003cp\u003eAspects of participants\u0026rsquo; environments acted as both barriers and facilitators to adopting the LwR:DSA.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBarrier\u003c/b\u003e. Inconvenient a\u003cem\u003eccess to resources\u003c/em\u003e was seen as a barrier to using the LwR:DSA in practice for participants who had difficulty keeping track of where to access the implementation strategies of the LwR:DSA (training videos, instruction guide, worksheets).\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacilitator\u003c/b\u003e. Strong \u003cem\u003enetworks and communication\u003c/em\u003e processes were identified as facilitators by participants working within collaborative, supportive, proactive, and well-functioning teams. A positive \u003cem\u003elearning climate\u003c/em\u003e was identified as a facilitator by those participants given time for self-reflection. \u003cem\u003eEngaged leadership\u003c/em\u003e further facilitated adoption. Unexpectedly, \u003cem\u003edisengaged leadership\u003c/em\u003e (leaders with large portfolios and minimal involvement) also functioned as a facilitator for some as it allowed greater autonomy and freedom to use the LwR:DSA in practice.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBoth a Facilitator and a Barrier\u003c/b\u003e. Organizational culture of participants\u0026rsquo; practice setting were both a facilitator and barrier. \u003cem\u003eCultures\u003c/em\u003e that valued innovation, prioritized improving the client experience, engaged in research, or strived for excellence were experienced as highly supportive of trying the LwR:DSA. Client-centred cultures that were tolerant of risk similarly facilitated use. Conversely, risk-averse cultures created barriers. For example, one participant noted concern that a risk-averse hospital would not support staff in the event of litigation related to LwR:DSA-guided decisions.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCompatibility\u003c/em\u003e facilitated use for participants who had autonomy in their practice, were able to integrate the LwR:DSA into existing workflows (e.g., care conferences, assessments), or could align it with existing team processes such as orientation. For others, compatibility acted as a barrier when practitioners were unsure how to incorporate the tool into existing documentation requirements or found that using it added extra time. One participant noted that embedding the LwR:DSA into their electronic medical record would enhance compatibility and ease of use.\u003c/p\u003e \u003cp\u003eChanges to the healthcare system during the pandemic increased some clients\u0026rsquo; risk for adverse events, which elevated the \u003cem\u003erelative priority\u003c/em\u003e of the LwR:DSA and facilitated its use. However, competing priorities, such as shifting to virtual care conferences or changes in clientele, lowered its priority for others, especially when they already had established processes for assessing and managing risk.\u003c/p\u003e \u003cp\u003e \u003cem\u003eTension for change\u003c/em\u003e was a facilitator for participants who were searching for a better way of providing client-centered risk assessment but a barrier for those who were satisfied with their current practice.\u003c/p\u003e \u003cp\u003e\u003cem\u003eAvailable resources\u003c/em\u003e was a facilitator for participants who used the LwR:DSA as a team but a barrier if there was not team buy-in. Participants described that using the LwR:DSA as a team promoted a common understanding and shared language which facilitated everyone being on the same page. However, lack of team buy-in, alongside broader constraints such as high workload, insufficient staffing, and HCP burnout, were described as significant barriers to implementing the LwR:DSA as a team-based process.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics related to the LwR:DSA (Innovation)\u003c/h2\u003e \u003cp\u003eParticipants described characteristics of the LwR:DSA that served as both barriers and facilitators to using it in practice.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFacilitator\u003c/b\u003e. Most participants viewed the LwR:DSA\u0026rsquo;s \u003cem\u003eevidence strength\u003c/em\u003e and \u003cem\u003equality\u003c/em\u003e and \u0026ldquo;low \u003cem\u003ecost\u003c/em\u003e\u0026rdquo; as facilitators to using it in practice.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBoth a facilitator and a barrier\u003c/b\u003e. The LwR:DSA\u0026rsquo;s \u003cem\u003erelative advantage\u003c/em\u003e was considered by participants as being both a barrier and facilitator to adoption. \u003cem\u003eRelative advantage\u003c/em\u003e was noted as a barrier by the participants who felt that it did not provide more value than current practice and a facilitator by those who experienced the benefits of using the LwR:DSA. Participants who found the LwR:DSA beneficial, described the LwR:DSA as useful, effective and applicable for a diversity of clients and clinical contexts. They valued its systematic and comprehensive structure and the way it formalized existing approaches to risk assessment.\u003c/p\u003e \u003cp\u003eThe \u003cem\u003eadaptability\u003c/em\u003e of the LwR:DSA was a facilitator for participants who were able to adapt the LwR:DSA to their clinical processes but a barrier for the participants who felt its \u003cem\u003eadaptability\u003c/em\u003e would hinder their team\u0026rsquo;s ability to know how to use it. Other participants indicated that the recommendations to reduce risk were only a small part of their overall recommendations to the client and therefore not adaptable to their full scope of practice.\u003c/p\u003e \u003cp\u003eThe LwR:DSA\u0026rsquo;s \u003cem\u003ecomplexity\u003c/em\u003e was a facilitator for those participants who described the LwR:DSA as simple, comprehensive, clear, concise, succinct, intuitive and easy to use, but a barrier for those who considered it complicated, overwhelming, time-consuming, confusing and repetitive. The professional \u003cem\u003edesign and overall quality\u003c/em\u003e of the LwR:DSA facilitated use for most participants. However, two participants identified the lack of a digitized version of the worksheets as a barrier, noting challenges with sharing summaries electronically with clients and caregivers or uploading them into electronic medical records.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics related to the HCPs (Individuals)\u003c/h2\u003e \u003cp\u003e \u003cb\u003eBoth a Facilitator and a Barrier\u003c/b\u003e. Participant characteristics acted as both facilitators and barriers to using the LwR:DSA in practice. Existing \u003cem\u003eknowledge\u003c/em\u003e of the LwR:DSA or a strong interest in risk assessment facilitated adoption for some participants. At the same time, limited experience with risk (i.e. new to the role or a recent graduate) also motivated some HCPs to use the LwR:DSA as a structured guide. Conversely, established \u003cem\u003eknowledge\u003c/em\u003e and approaches to risk assessment and management created a barrier for participants who felt the LwR:DSA did not align with their usual practice. Several participants also described simply \u0026ldquo;forgetting\u0026rdquo; to use the LwR:DSA, highlighting another barrier.\u003c/p\u003e \u003cp\u003e \u003cem\u003eOther personal attributes\u003c/em\u003e emerged from the data that were both facilitators and barriers to using the LwR:DSA in practice. Knowledge of topics helpful for learning about the LwR:DSA (i.e. the PIECES framework, motivational interviewing), having a commitment to client choice, or using a biopsychosocial lens were considered facilitators. Participants who described themselves as proactive, systematic, improvement-oriented, or motivated to support the study\u0026rsquo;s goals also reported that these attributes enhanced their ability to integrate the LwR:DSA. In contrast, \u003cem\u003epersonal attributes\u003c/em\u003e that limited use included feeling comfortable with current practice, reluctance to be guided by a structured tool, or a desire to \u0026ldquo;figure out\u0026rdquo; risk assessment independently before adopting a new approach.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCharacteristics related to the Implementation Process (Implementation Process)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eParticipants highlighted elements of the implementation process that were both barriers and facilitators to using the LwR:DSA.\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacilitator\u003c/b\u003e. Having an internal champion to support the LwR:DSA in practice was considered a facilitator for \u003cem\u003eengaging\u003c/em\u003e in implementation. Champions supported engagement by helping participants learn how to integrate the LwR:DSA into practice and by serving as accessible problem-solvers during early use.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBoth a Facilitator and a Barrier\u003c/b\u003e. Time was a central factor during implementation process. Having dedicated time to learn and practice using the LwR:DSA facilitated adoption, whereas limited time created a barrier. Implementing the tool as a team further supported adoption by enabling shared learning, consistent use, and collective problem-solving; however, when team involvement was not possible, this limited the ease of implementation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo inform broader implementation of the LwR:DSA, this study sought to identify multi-level determinants of adoption using the CFIR\u0026rsquo;s five domains. We first characterized the level of LwR:DSA adoption among multidisciplinary hospital- and community-based HCPs, followed by an examination of the barriers and facilitators they encountered while preparing for use and adopting the LwR:DSA for eight weeks. Interpreting these determinants alongside the observed adoption level provides important insight into the conditions that supported or constrained LwR:DSA adoption and clarifies the types of implementation supports that may be required for sustained integration. Understood together, this integrated view of adoption levels and determinants provides a foundation for tailoring implementation strategies that can strengthen and sustain LwR:DSA use in real-world practice.\u003c/p\u003e \u003cp\u003eAdoption was defined as the number of clients with whom participants used the LwR:DSA and was measured through self-report. A high proportion (80%) of participants adopted the LwR:DSA at least once over the eight-week period. Although successful uptake has been described as a greater than 50% increase in intervention use [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], high adoption rates remain uncommon. For example, decision support tools typically demonstrate adoption rates ranging from 3%\u0026ndash;28% [\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAcross CFIR\u0026rsquo;s 39 constructs, participants identified 19 facilitators and 14 barriers to LwR:DSA adoption, across all five CFIR domains. Thirteen constructs functioned as both barriers and facilitators, suggesting that their influence on adoption was contextual, dynamic, and often nuanced. The greater number of facilitators aligns with the high adoption rate observed. Conversely, the identified barriers may reflect determinants that negatively influence adherence or \u003cem\u003esustained\u003c/em\u003e use rather than initial uptake alone. Taken together, distinguishing which barriers require targeted strategies and which facilitators can be leveraged, provides essential guidance for supporting future implementation and sustainability of the LwR:DSA specifically and more broadly decision support tools in healthcare settings.\u003c/p\u003e \u003cp\u003eThe results of this study highlighted with whom (Outer Setting) the LwR:DSA\u0026rsquo;s use was perceived to be most helpful in meeting clients\u0026rsquo; needs. Client situations of uncertainty driven by multiple or new concerns, cognitive impairment, lack of support or complexity appeared to increase the perceived value of adopting the LwR:DSA. Additionally, the LwR:DSA was found to help navigate disagreements about care plans and/or next steps between HCPs within the team, between the HCP and the client, or between the client and their caregiver. These reasons for use are consistent with those identified in the earlier LwR:DSA validation and adaptation study [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], while offering additional contextual detail in how social and relational dynamics influence use.\u003c/p\u003e \u003cp\u003eCaregiver involvement emerged as a particularly nuanced determinant. For some participants, the presence of an engaged caregiver facilitated use of the LwR:DSA by enabling shared understanding and collaborative risk management. In contrast, other participants perceived caregiver involvement as reducing overall risk, which in turn diminished the perceived need to use the LwR:DSA. This interpretation suggests that caregiver presence may be conflated with risk resolution rather than recognized as an opportunity to engage in structured shared decision-making. A similar tension was observed in relation to cognitive impairment, while some HCPs viewed shared decision-making as infeasible in this context, a perception noted in prior research [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], others have emphasized the importance of involving people living with dementia and their caregivers in risk communication particularly given the quality of life implications of risk mitigation strategies [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. It is critical therefore, to specifically address potential adoption issues among HCPs who assume that people with cognitive impairments are not able to participate in risk assessment. This is particularly important as people with cognitive impairment and their family caregivers may be a key group to assist in risk management through the use of the LwR:DSA.\u003c/p\u003e \u003cp\u003eCompatibility was a prominent Inner Setting construct influencing HCPs\u0026rsquo; ability to adopt the LwR:DSA. Participants described fitting the LwR:DSA into their existing practice as a key facilitator, whereas the added time required to use the LwR:DSA was the primary barrier. Lack of time is a consistent theme across implementation studies [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], including those focused on shared decision-making [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. More specifically, insufficient time to learn new methods [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], the need for protected implementation time [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], and the time demands of education and mentoring [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] were all also identified in this study as time barriers. This perceived time burden may also reflect challenges aligning the LwR:DSA with current workflows. The broader implementation literature also emphasized the importance of integrating innovations into existing workflows, particularly for shared decision-making [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] and clinical decision support tools [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Since implementing any innovation inevitably requires additional time, understanding how to integrate the LwR:DSA into existing practices and workflows could help leverage this facilitator while also reducing the perceived barrier of increased time and workload.\u003c/p\u003e \u003cp\u003eFindings suggested that team-based adoption of the LwR:DSA functioned as an Inner Setting facilitator, particularly by addressing resource constraints and risk aversion. Rather than merely increasing participation, collective team use appeared to redistribute the cognitive and relational workload associated with adopting an innovation, thereby enhancing perceived feasibility and sustainability. Shared adoption of the LwR:DSA may also have strengthened collective efficacy by promoting a common language, aligning risk thresholds and normalizing shared accountability for complex decisions. Findings align with broader implementation research demonstrating that interprofessional collaboration, team buy-in, and whole-team training facilitate adoption of shared decision-making and decision support tools [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] and supports evidence that implementation is more likely to be sustained when change is enacted at the team rather than the individual level [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough participants engaged in the study as individuals rather than as part of an organizational initiative, leadership support still emerged as an Inner Setting facilitator, reinforcing leadership engagement as a core component of implementation readiness [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This finding is consistent with literature emphasizing leadership support [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] and leader encouragement [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] as important facilitators. Interestingly, some participants also described disengaged leadership as a facilitator, suggesting that autonomy in clinical decision-making may support initial use of the LwR:DSA.\u003c/p\u003e \u003cp\u003ePerceived complexity of the LwR:DSA (Innovation) functioned as both a barrier and facilitator to adoption. Some participants found the LwR:DSA straight forward, intuitive and easy to use while others described it as confusing, complicated, and overwhelming. In the previous validation and adaptation study, worksheets were developed at the request of HCPs to operationalize the LwR:DSA [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, in the present study, the number of worksheets may have contributed to perceptions of complexity. Although tools and worksheets are recognized facilitators of implementing decision support tools [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and shared decision-making [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], they must remain simple and user-friendly to avoid competing with existing priorities and workflow demands [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe HCP\u0026rsquo;s (Individual) knowledge of the LwR:DSA, risk and their experience in risk assessment was both a barrier and facilitator to adoption which is consistent with existing literature. Having the knowledge and experience in using a tool was seen as a facilitator for implementation of a decision support tool for decisional capacity assessment [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] and practicing foundational concepts such as person-centred care was a facilitator for shared decision-making [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and the LwR:DSA. However, experience can also be a barrier to adoption if HCPs feel that they do this skill already [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] which was highlighted by some participants in this study.\u003c/p\u003e \u003cp\u003eHaving time to learn and practice the LwR:DSA (Implementation Process) facilitated successful LwR:DSA adoption and is substantiated in the literature [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Participants of this study also indicated that having a champion would facilitate use by promoting the innovation, demonstrating how it could be integrated into practice, answering questions about, reminding to use and supporting how to use. These functions of a champion align closely with prior studies demonstrating the value of champions in implementing both shared decision-making and decision support tools [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Additionally, using champions can have an additive effect by reinforcing and sustaining new learning related to the innovation.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrengths\u003c/h2\u003e \u003cp\u003eThis study has several strengths that enhance the credibility, rigor and practical usefulness of the findings. First, using a well-established determinants framework represents a key strength. Applying the CFIR enabled a comprehensive, multi-level exploration of determinants, particularly because participants did not spontaneously reflect on determinants across all five domains. Notably, all participants required structured probing to elicit individual-level influences on adoption which many did not initially recognize as shaping their implementation decisions.\u003c/p\u003e \u003cp\u003eA second strength was recruiting participants who used the LwR:DSA within their own clinical practice. This pragmatic approach generated rich, high-quality data about adoption, an important consideration when prioritizing depth and information power over traditional notions of data saturation [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Studying determinants under real-world conditions provided meaningful insights into a practical clinical problem. By mirroring how HCPs might practically encounter the LwR:DSA following a presentation allowed for realistic observations of early adoption processes. Similarly, instructing HCPs to integrate the tool into their usual care offered an authentic view of determinants operating under typical conditions, including the complexity and resource constraints commonly described by HCPs working with older adults [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] and those conducting risk assessments [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe rigor of the qualitative data was further supported through strategies that enhanced authenticity and credibility [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. For instance, creating space for open dialogue and using a data-driven coding approach to ensure participants\u0026rsquo; perspectives were accurately represented. Together, these strategies strengthened confidence in the trustworthiness and applicability of the findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eAlthough this study offers important insights into the adoption of the LwR:DSA, several limitations should be considered when interpreting the findings. First, the high adoption rate limits the generalizability of the findings to a general population of HCPs as the participants had a high interest in risk, worked within innovative cultures, had positive relationships with colleagues and leaders, were experienced (10\u0026thinsp;+\u0026thinsp;years) and were able to take part in a study over eight weeks during a time of competing priorities (related to a pandemic). This type of proactive personality has been associated with innovative work behaviour [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e], increased adoption [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e], and ability to scan for and create opportunities during times of uncertainty such as the recent pandemic [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. As such, barriers identified by these participants may warrant greater weight for generalizability than the facilitators they described.\u003c/p\u003e \u003cp\u003eSecond, adoption was self-reported and some participants were known to the lead researcher (from participation in a previous study of the LwR:DSA or were previous colleagues) which may have introduced social desirability bias [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. While this possibility cannot be excluded, several factors increase confidence in the accuracy of the reported adoption rates: participants submitted completed worksheets and study logs, two HCPs openly reported not using the LwR:DSA during the eight weeks, and most participants acknowledged they could have used the tool more frequently. These elements provided a degree of accountability and suggest that reported adoption was not uniformly inflated.\u003c/p\u003e \u003cp\u003eFinally, it is possible that eight weeks of use was not sufficient time to learn a new approach to care and integrate into practice. However, many studies elicit anticipated barriers and facilitators from knowledge users without implementation [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Given that the data were collected following use of the LwR:DSA, the data presented in this chapter are actual barriers and facilitators, and another strength of the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Practice and Research\u003c/h2\u003e \u003cp\u003eOur findings support ongoing efforts to integrate the LwR:DSA into routine practice. Understanding the barriers and facilitators to adoption is essential for selecting and tailoring implementation strategies that address modifiable challenges while leveraging existing strengths. As determinants were identified across all five CFIR domains (Outer Setting, Inner Setting, Innovation, Characteristics of Individuals, and Implementation Process), future implementation efforts will require \u003cb\u003emulti-level strategies\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eFor instance, an implementation guide could outline with whom the LwR:DSA is most appropriate to use (Outer Setting), and include discussion of situations where an HCP may hesitate to use it (e.g., patient with cognitive impairment or is viewed as having strong family support), how it can be integrated into existing workflows (Inner Setting), and which processes best support implementation, such as designating champions and using the LwR:DSA as a team (Implementation Process). Simplifying aspects of the LwR:DSA may also help reduce perceived complexity (Innovation). Introducing a \u0026ldquo;coaching conversations\u0026rdquo; worksheet may support the types of discussions already occurring in clinical practice, while additional training modules could enhance HCPs\u0026rsquo; foundational knowledge and skills (Characteristics of Individuals). Highlighting the importance of establishing favourable conditions for adoption, such as supportive relationships, an innovative culture, and a positive learning climate, may further strengthen readiness for implementation.\u003c/p\u003e \u003cp\u003eFuture research should focus on monitoring knowledge use and evaluating outcomes (e.g. improved client engagement, improved clinical thinking, decision-making and communication, decreased moral distress and improved team processes) of using the LwR:DSA [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Also, as the LwR:DSA has predominantly only been studied with HCPs, future research should focus on the older adult\u0026rsquo;s perspective of the LwR:DSA and whether this approach supports their decisional needs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eRisk assessment and management remains a highly relevant clinical challenge, as current practice often defaults to over-protective approaches that may unintentionally cause harm. The LwR:DSA offers a more balanced, systematic, and person-centred method for identifying and managing risk. This study provides important insights into the determinants influencing its adoption in real-world clinical settings. Findings highlight the need to target modifiable determinants across multiple domains, including clarifying contexts for use, supporting integration into existing workflows, and strengthening team-based adoption through leadership engagement and champion support.\u003c/p\u003e \u003cp\u003eImportantly, the LwR:DSA may represent a scalable, low-cost systems intervention capable of supporting quality and safety objectives while preserving person-centred care. Although lack of time is frequently cited as a barrier, system-level strategies, including embedding the LwR:DSA within documentation systems and clinical pathways, allocating protected time for training, and fostering organizational cultures that value balanced approaches to risk, can create the conditions necessary for successful adoption. These findings underscore that implementation of the LwR:DSA should not be viewed solely as an individual HCP responsibility but as an organizational and policy priority aligned with improving quality of care, supporting autonomy, and strengthening shared decision-making for older adults.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cp\u003eCFIR Consolidated Framework for Implementation Research\u003c/p\u003e \u003cp\u003eCOREQ Consolidated Criteria for Reporting Qualitative Research (COREQ)\u003c/p\u003e \u003cp\u003eHCPs Healthcare Professionals\u003c/p\u003e \u003cp\u003eLwR:DSA Living with Risk: Decision Support Approach\u003c/p\u003e \u003cp\u003eOT Occupational Therapist\u003c/p\u003e \u003cp\u003ePT Physiotherapist\u003c/p\u003e \u003cp\u003eRN Registered Nurse\u003c/p\u003e \u003cp\u003eSW Social Worker\u003c/p\u003e "},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThis study obtained ethics approval from Queen\u0026rsquo;s University Health Sciences \u0026amp; Affiliated Teaching Hospitals Research Ethics Board (REH-815-21). All methods were carried out in accordance with this institutional ethics review board\u0026rsquo;s guidelines and regulations. Informed consent was obtained from all participants in advance of data collection.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e This study obtained financial support from the Canadian Institutes of Health Research\u0026rsquo;s Knowledge Translation Catalyst Grant: Quadruple Aim and Equity (475339) In-kind donations were provided by CIUSS de l\u0026rsquo;Estrie-CHUS, Users\u0026rsquo; Committee for the CHUS, Research Centre on Aging (Universit\u0026eacute; de Sherbrooke), Universit\u0026eacute; de Sherbrooke, Regroupement des unit\u0026eacute;s de courte dur\u0026eacute;e g\u0026eacute;riatriques et des services hospitaliers g\u0026eacute;riatriques du Qu\u0026eacute;bec, and Regional Geriatric Program of Eastern Ontario. None of the financial or in-kind funders had any role in the study design, data collection, analysis, data interpretation or writing the manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHM, DK, KBL and VP contributed to the conception of study, study design, interpretation of data, and co-creation of draft manuscript. NDC, ME, NV, DG, MJL and JK collaborated to the data interpretation and revised the draft manuscript. All authors have reviewed and approved the submitted version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank the health care professionals who took part in this study during a time of uncertainty, increased workload and competing priorities related to the COVID-19 pandemic. The authors would also like to thank the research assistant involved in this project, namely Monia D\u0026rsquo;Amours. HM would like to thank her doctoral defence committee Kathryn Sibley, Jennifer Tomasone and Catherine Donnelly for their invaluable input.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data generated and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFelton A, Wright N, Stacey G. Therapeutic risk-taking: A justifiable choice. Br J Psychol Adv. 2017;23(2):81\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1192/apt.bp.115.015701\u003c/span\u003e\u003cspan address=\"10.1192/apt.bp.115.015701\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlovic P, Peters E. Risk perception and affect. Curr Dir Psychol Sci. 2006;15(6):322\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1467-8721.2006.00461.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1467-8721.2006.00461.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDurocher E, Kinsella EA. Ethical tensions in occupational therapy practice: Conflicts and competing allegiances. Can J Occup Ther. 2021;88(3):244\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/00084174211021707\u003c/span\u003e\u003cspan address=\"10.1177/00084174211021707\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoats G. Discharge decision-making, enabling occupations, and client-centred practice. Can J Occup Ther. 2007;74(2):91\u0026ndash;101. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/000841740707400203\u003c/span\u003e\u003cspan address=\"10.1177/000841740707400203\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eD\u0026eacute;sormeaux-Moreau M, Aubin G, Larivi\u0026egrave;re N, S\u0026Eacute;CuRE. A clinical tool for comprehensively assessing home safety of people with mental illness. Br J Occup Ther. 2018;81(9):503\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0308022618762085\u003c/span\u003e\u003cspan address=\"10.1177/0308022618762085\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee L, Hillier LM, Lu SK, Martin SD, Pritchard S, Janzen J, Slonim K. Person-centered risk assessment framework: assessing and managing risk in older adults living with dementia. Neurodegener Dis Manag. 2019;9(1):47\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2217/nmt-2018-0031\u003c/span\u003e\u003cspan address=\"10.2217/nmt-2018-0031\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor BJ. Risk-managing decision-making: A psycho-social rationality model. Br J Soc Work. 2021;51(7):2819\u0026ndash;38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1471301217704119\u003c/span\u003e\u003cspan address=\"10.1177/1471301217704119\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTitterton M. Risk and risk taking in health and social welfare. London: Jessica Kingsley; 2005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacLeod H, Stadnyk R, Risk. I know it when I see it: how health and social practitioners defined and evaluated living at risk among community-dwelling older adults. Health Risk Soc. 2015;17(1):46\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/13698575.2014.999749\u003c/span\u003e\u003cspan address=\"10.1080/13698575.2014.999749\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacLeod H, Veillette N, Klein J, Delli-Colli N, Egan M, Giroux D, et al. Shifting the narrative from living at risk to living with risk: validating and pilot-testing a clinical decision support tool: a mixed methods study. BMC Geriatr. 2023;23(1):1\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12877-023-04068-w\u003c/span\u003e\u003cspan address=\"10.1186/s12877-023-04068-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProctor E, Ramsey AT, Saldana L, Maddox TM, Chambers DA, Brownson RC. FAST: a framework to assess speed of translation of health innovations to practice and policy. Glob Implement Res Appl. 2022;2(2):107\u0026ndash;19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s43477-022-00045-4\u003c/span\u003e\u003cspan address=\"10.1007/s43477-022-00045-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrownson RC, Colditz GA, Proctor EK, editors. Dissemination and Implementation Research in Health: Translating Science to Practice. 2nd ed. Oxford: Oxford University Press; 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/oso/9780190683214.001.0001\u003c/span\u003e\u003cspan address=\"10.1093/oso/9780190683214.001.0001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEccles M, Mittman B. Welcome to Implementation Science. Implement Sci. 2006;1(1):1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1748-5908-1-1\u003c/span\u003e\u003cspan address=\"10.1186/1748-5908-1-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBauer M, Damschroder L, Hagedorn H, Smith J, Kilbourne A. An introduction to implementation science for the non-specialist. BMC Psychol. 2015;3(1):32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s40359-015-0089-9\u003c/span\u003e\u003cspan address=\"10.1186/s40359-015-0089-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHughes JM, Zullig LL, Choate AL, et al. Intensification of Implementation Strategies: Developing a Model of Foundational and Enhanced Implementation Approaches to Support National Adoption and Scale-up. Gerontologist. 2023;63(3):604\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/geront/gnac130\u003c/span\u003e\u003cspan address=\"10.1093/geront/gnac130\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKilbourne AM, Smith SN, Choi SY, et al. Adaptive School-based Implementation of CBT (ASIC): clustered-SMART for building an optimized adaptive implementation intervention to improve uptake of mental health interventions in schools. Implement Sci. 2018;13(1):119. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13012-018-0808-8\u003c/span\u003e\u003cspan address=\"10.1186/s13012-018-0808-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis CC, Scott K, Marti CN, et al. Implementing measurement-based care (iMBC) for depression in community mental health: a dynamic cluster randomized trial study protocol. Implement Sci. 2015;10:127. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13012-015-0313-2\u003c/span\u003e\u003cspan address=\"10.1186/s13012-015-0313-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2015 Sep 7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, Robinson N. Lost in knowledge translation: Time for a map? J Contin Educ Health Prof. 2006;26(1):13\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/chp.47\u003c/span\u003e\u003cspan address=\"10.1002/chp.47\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDamschroder L, Aron D, Keith R, Kirsh S, Alexander J, Lowery J. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1748-5908-4-50\u003c/span\u003e\u003cspan address=\"10.1186/1748-5908-4-50\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoullin JC, Dickson KS, Stadnick NA, Albers B, Nilsen P, Broder-Fingert S, et al. Ten recommendations for using implementation frameworks in research and practice. Implement Sci Commun. 2020;1:1\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s43058-020-00023-7\u003c/span\u003e\u003cspan address=\"10.1186/s43058-020-00023-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaltz T, Powell B, Fern\u0026aacute;ndez M, Abadie B, Damschroder L. Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions. Implement Sci. 2019;14(1):42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13012-019-0892-4\u003c/span\u003e\u003cspan address=\"10.1186/s13012-019-0892-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeeman J, Birken SA, Powell BJ, Rohweder C, Shea CM. Beyond implementation strategies: classifying the full range of strategies used in implementation science and practice. Implement Sci. 2017;12(1):125. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13012-017-0657-x\u003c/span\u003e\u003cspan address=\"10.1186/s13012-017-0657-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowles KH, Holland DE, Potashnik SL. Implementation and testing of interdisciplinary decision support tools to standardize discharge planning. NI 2012 (2012). 2012;2012:41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBr\u0026eacute;mault-Phillips SC, Parmar J, Friesen S, Rogers LG, Pike A, Sluggett B. An evaluation of the decision-making capacity assessment model. Can Geriatr J. 2016;19(3):83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5770/cgj.19.222\u003c/span\u003e\u003cspan address=\"10.5770/cgj.19.222\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDobler CC, Sanchez M, Gionfriddo MR, et al. Impact of decision aids used during clinical encounters on clinician outcomes and consultation length: a systematic review. BMJ Qual Saf. 2019;28(6):499\u0026ndash;510. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjqs-2018-008022\u003c/span\u003e\u003cspan address=\"10.1136/bmjqs-2018-008022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoseph-Williams N, Lloyd A, Edwards A, Stobbart L, Tomson D, Macphail S, et al. Implementing shared decision making in the NHS: lessons from the MAGIC programme. BMJ. 2017;357:j1744. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmj.j1744\u003c/span\u003e\u003cspan address=\"10.1136/bmj.j1744\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci. 2016;11:72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13012-016-0437-z\u003c/span\u003e\u003cspan address=\"10.1186/s13012-016-0437-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2016 May 17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMertz E, Wides C, White J. Clinician attitudes, skills, motivations and experience following the implementation of clinical decision support tools in a large dental practice. J Evid Based Dent Pract. 2017;17(1):1\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jebdp.2016.10.001\u003c/span\u003e\u003cspan address=\"10.1016/j.jebdp.2016.10.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsheroff JA, Teich JM, Middleton B, Steen EB, Wright A, Detmer DE. A roadmap for national action on clinical decision support. J Am Med Inf Assoc. 2007;14(2):141\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1197/jamia.M2334\u003c/span\u003e\u003cspan address=\"10.1197/jamia.M2334\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePowell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10:21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13012-015-0209-1\u003c/span\u003e\u003cspan address=\"10.1186/s13012-015-0209-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScholl I, LaRussa A, Hahlweg P, Kobrin S, Elwyn G. Organizational- and system-level characteristics that influence implementation of shared decision-making and strategies to address them\u0026mdash;a scoping review. Implement Sci. 2018;13(1):1\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13012-018-0731-z\u003c/span\u003e\u003cspan address=\"10.1186/s13012-018-0731-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSch\u0026ouml;n UK, Grim K, Wallin L, Rosenberg D, Svedberg P. Psychiatric service staff perceptions of implementing a shared decision-making tool: a process evaluation study. Int J Qual Stud Health Well-being. 2018;13(1):1421352. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/17482631.2017.1421352\u003c/span\u003e\u003cspan address=\"10.1080/17482631.2017.1421352\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan AS, Mazor KM, McDonald D, Lee SJ, McNeal D, Matlock DD, Glasgow RE. Designing shared decision-making interventions for dissemination and sustainment: can implementation science help translate shared decision making into routine practice? MDM Policy Pract. 2018;3(2):2381468318808503.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38:65\u0026ndash;76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10488-010-0319-7\u003c/span\u003e\u003cspan address=\"10.1007/s10488-010-0319-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLumivero. NVivo (Version 14) [software]. Denver (CO): Lumivero; 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.lumivero.com\u003c/span\u003e\u003cspan address=\"https://www.lumivero.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMicrosoft Corporation. (2024). \u003cem\u003eMicrosoft Excel\u003c/em\u003e. Retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://office.microsoft.com/excel\u003c/span\u003e\u003cspan address=\"https://office.microsoft.com/excel\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNicmanis M. Reflexive content analysis: An approach to qualitative data analysis, reduction, and description. Int J Qual Methods. 2024;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/16094069241236603\u003c/span\u003e\u003cspan address=\"10.1177/16094069241236603\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevine R, Zingelman S, McSween MP, Shrubsole K, Hill AJ, Copland DA. Allied Health Clinicians' Uptake of Evidence in Stroke Rehabilitation: A Systematic Review of Determinants Targeted in Implementation Studies. Arch Phys Med Rehabil. 2024;105(5):988\u0026ndash;99. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.apmr.2023.08.018\u003c/span\u003e\u003cspan address=\"10.1016/j.apmr.2023.08.018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrunner J, Farmer MM, Bean-Mayberry B, et al. Implementing clinical decision support for reducing women Veterans' cardiovascular risk in VA: A mixed-method, longitudinal study of context, adaptation, and uptake. Front Health Serv. 2022;2:946802. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/frhs.2022.946802\u003c/span\u003e\u003cspan address=\"10.3389/frhs.2022.946802\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePurkey E, Bayoumi I, Coo H, et al. Exploratory study of real world implementation of a clinical poverty tool in diverse family medicine and pediatric care settings. Int J Equity Health. 2019;18(1):200. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12939-019-1085-0\u003c/span\u003e\u003cspan address=\"10.1186/s12939-019-1085-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2019 Dec 23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilvestrin TM, Steenrod AW, Coyne KS, et al. An approach to improve the care of mid-life women through the implementation of a Women's Health Assessment Tool/Clinical Decision Support toolkit. Womens Health (Lond). 2016;12(5):456\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1745505716664742\u003c/span\u003e\u003cspan address=\"10.1177/1745505716664742\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePel-Littel RE, Snaterse M, Teppich NM, Buurman BM, van Etten-Jamaludin FS, van Weert JC, et al. Barriers and facilitators for shared decision making in older patients with multiple chronic conditions: a systematic review. BMC Geriatr. 2021;21:1\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12877-021-02050-y\u003c/span\u003e\u003cspan address=\"10.1186/s12877-021-02050-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStevenson M, Savage B, Taylor BJ. Perception and Communication of Risk in Decision Making by Persons with Dementia. Dement (London). 2019;18(3):1108\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1471301217704119\u003c/span\u003e\u003cspan address=\"10.1177/1471301217704119\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaddell A, Lennox A, Spassova G, Bragge P. Barriers and facilitators to shared decision-making in hospitals from policy to practice: a systematic review. Implement Sci. 2021;16:1\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13012-021-01142-y\u003c/span\u003e\u003cspan address=\"10.1186/s13012-021-01142-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoland L, Lawson ML, Graham ID, L\u0026eacute;gar\u0026eacute; F, Dorrance K, Shephard A, Stacey D. Post-training shared decision making barriers and facilitators for pediatric healthcare providers: A mixed-methods study. Acad Pediatr. 2019;19(1):118\u0026ndash;29. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.acap.2018.05.010\u003c/span\u003e\u003cspan address=\"10.1016/j.acap.2018.05.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElwyn G, Scholl I, Tietbohl C, Mann M, Edwards AG, Clay C, et al. Many miles to go\u0026hellip;a systematic review of the implementation of patient decision support interventions into routine clinical practice. BMC Med Inform Decis Mak. 2013;13(Suppl 2):S14. doi:10.1186/1472-6947-13-S2-S14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParmar J, Sacrey LA, Anderson S, Charles L, Dobbs B, McGhan G, et al. Facilitators, barriers and considerations for the implementation of healthcare innovation: a qualitative rapid systematic review. Health Soc Care Community. 2022;30(3):856\u0026ndash;68. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/hsc.13578\u003c/span\u003e\u003cspan address=\"10.1111/hsc.13578\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBr\u0026eacute;mault-Phillips S, Pike A, Charles L, Roduta-Roberts M, Mitra A, Friesen S, et al. Facilitating implementation of the Decision-Making Capacity Assessment (DMCA) Model: senior leadership perspectives on the use of the National Implementation Research Network (NIRN) Model and frameworks. BMC Res Notes. 2018;11:1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13104-018-3714-x\u003c/span\u003e\u003cspan address=\"10.1186/s13104-018-3714-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMunro S, Manski R, Donnelly KZ, Agusti D, Stevens G, Banach M, et al. Investigation of factors influencing the implementation of two shared decision-making interventions in contraceptive care: a qualitative interview study among clinical and administrative staff. Implement Sci. 2019;14:1\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.14288/1.0385167\u003c/span\u003e\u003cspan address=\"10.14288/1.0385167\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoseph-Williams N, Abhyankar P, Boland L, Bravo P, Brenner AT, Brodney S, et al. What works in implementing patient decision aids in routine clinical settings? A rapid realist review and update from the International Patient Decision Aid Standards Collaboration. Med Decis Mak. 2021;41(7):907\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0272989X20978208\u003c/span\u003e\u003cspan address=\"10.1177/0272989X20978208\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarding KE, Porter J, Horne-Thompson A, Donley E, Taylor NF. Not enough time or a low priority? Barriers to evidence-based practice for allied health clinicians. J Contin Educ Health Prof. 2014;34(4):224\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/chp.21255\u003c/span\u003e\u003cspan address=\"10.1002/chp.21255\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGuier EA, Aarons GA, Byrne KA et al. Associations between teamwork and implementation outcomes in multidisciplinary cross-sector teams implementing a mental health screening and referral protocol. Implement Sci Commun. 2023;4(1):13. Published 2023 Feb 10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s43058-023-00393-8\u003c/span\u003e\u003cspan address=\"10.1186/s43058-023-00393-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMathieson A, Grande G, Luker K. Strategies, facilitators and barriers to implementation of evidence-based practice in community nursing: a systematic mixed-studies review and qualitative synthesis. Prim Health Care Res Dev. 2019;20:e6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/S1463423618000488\u003c/span\u003e\u003cspan address=\"10.1017/S1463423618000488\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1049732315617444\u003c/span\u003e\u003cspan address=\"10.1177/1049732315617444\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrouwers C, Merten H, Willems M, et al. Improving care for older patients in the acute setting: a qualitative study with healthcare providers. Neth J Med. 2017;75(8):335\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePloeg J, Yous ML, Fraser K, et al. Healthcare providers' experiences in supporting community-living older adults to manage multiple chronic conditions: a qualitative study. BMC Geriatr. 2019;19(1):316. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12877-019-1345-2\u003c/span\u003e\u003cspan address=\"10.1186/s12877-019-1345-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKemshall H. Bias and error in risk assessment and management. HM Inspectorate Probat Acad Insights. 2021;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell JW, Creswell JD. Qualitative methods. Research Design: Qualitative, Quantitative and Mixed Methods Approaches. Thousand Oaks (CA): Sage Publications Inc; 2018. pp. 179\u0026ndash;211.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMilne J, Oberle K. Enhancing rigor in qualitative description. J Wound Ostomy Cont Nurs. 2005;32(6):413\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00152192-200511000-00014\u003c/span\u003e\u003cspan address=\"10.1097/00152192-200511000-00014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMubarak N, Khan J, Yasmin R, Osmadi A. The impact of a proactive personality on innovative work behavior: the role of work engagement and transformational leadership. Leadersh Organ Dev J. 2021;42(7):989\u0026ndash;1003. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1108/LODJ-11-2020-0518\u003c/span\u003e\u003cspan address=\"10.1108/LODJ-11-2020-0518\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKandah A, Ehrhart M, Sklar M, Aarons G, Implementation in Health. Who is going to implement? [conference presentation]. 17th Annual Conference on the Science of Dissemination and ; 2024 Dec 8\u0026ndash;11; Arlington, VA: Academy Health. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://academyhealth.org/events/2024-12/17th-annual-conference-science-dissemination-and-implementation\u003c/span\u003e\u003cspan address=\"https://academyhealth.org/events/2024-12/17th-annual-conference-science-dissemination-and-implementation\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYi-Feng Chen N, Crant JM, Wang N, Kou Y, Qin Y, Yu J, Sun R. When there is a will there is a way: the role of proactive personality in combating COVID-19. J Appl Psychol. 2021;106(2):199. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/apl0000865\u003c/span\u003e\u003cspan address=\"10.1037/apl0000865\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBispo J\u0026uacute;nior JP. Social desirability bias in qualitative health research. Rev Saude Publica. 2022;56:101. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.11606/s1518-8787.2022056004164\u003c/span\u003e\u003cspan address=\"10.11606/s1518-8787.2022056004164\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDolansky MA, Pohnert A, Ball S, McCormack M, Hughes R, Pino L. Pre-implementation of the age-friendly health systems evidence-based 4Ms framework in a multi-state convenient care practice. Worldviews Evid Based Nurs. 2021;18(2):118\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/wvn.12498\u003c/span\u003e\u003cspan address=\"10.1111/wvn.12498\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarry ML, Truitt AR, Saman DM, Henzler-Buckingham HA, Allen CI, Walton KM, et al. Barriers and facilitators to implementing cancer prevention clinical decision support in primary care: a qualitative study. BMC Health Serv Res. 2019;19:1\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-019-4326-4\u003c/span\u003e\u003cspan address=\"10.1186/s12913-019-4326-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"risk assessment, risk management, clinical decision-making, Consolidated Framework for Implementation Research, adoption, barriers and facilitators, older adults, safety concerns, shared decision-making.","lastPublishedDoi":"10.21203/rs.3.rs-8865683/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8865683/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe \u003cem\u003eLiving with Risk: Decision Support Approach\u003c/em\u003e (LwR:DSA) was developed to address the lack of structured approaches for assessing and managing risk among healthcare professionals (HCPs) supporting older adults with perceived safety concerns. Early use of the LwR:DSA demonstrated potential to expand person-centred, balanced discussions of risk; however, strategies to support its adoption in hospital and community settings remain unclear. This study aimed to describe LwR:DSA adoption and identify multilevel barriers and facilitators influencing its adoption so that the tool and implementation strategies could be appropriately tailored.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA multimethod implementation study was conducted. Quantitative survey data were analysed descriptively, and qualitative interview data were analysed using reflexive content analysis guided by the five domains of the Consolidated Framework for Implementation Research (CFIR). Findings were integrated and categorized across the five CFIR domains to identify multilevel determinants influencing adoption.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf 26 participants, eighty percent adopted the LwR:DSA at least once during an eight-week implementation period and identified 20 determinants across all CFIR domains. Six constructs acted solely as facilitators, one as a barrier, and thirteen as mixed determinants. Key determinants of LwR:DSA adoption were knowing with whom to use the LwR:DSA (Outer Setting), knowing how to integrate into practice, using the LwR:DSA as a team, having supportive leadership, working in an innovative workplace with good relationships with colleagues (Inner Setting), finding the LwR:DSA easy to use (Innovation), having an in-depth foundational knowledge related to the LwR:DSA (HCPs) and using champions (Implementation Process).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eApplication of the CFIR provided a comprehensive understanding of multilevel factors influencing LwR:DSA adoption across hospital and community settings. These determinants can be leveraged to inform the selection and tailoring of implementation strategies to enhance uptake and sustainability. Embedding these determinants within future implementation efforts offers a practical pathway to strengthen person-centred, risk-informed decision-making practices across geriatric care contexts.\u003c/p\u003e","manuscriptTitle":"Barriers and Facilitators to Adopting a Risk Assessment and Management Decision Support Approach For Safety Concerns of Older Adults: a Multimethods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-20 12:41:31","doi":"10.21203/rs.3.rs-8865683/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-16T14:00:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243026483228369068893695233865495302928","date":"2026-05-13T20:19:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29434581034263274136531373126947342997","date":"2026-05-07T18:19:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-05T14:41:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-09T12:19:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-14T06:59:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-14T06:58:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-02-12T21:20:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"750de87b-8526-4a09-b6a7-e9f4301f27e3","owner":[],"postedDate":"February 20th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-16T14:00:04+00:00","index":71,"fulltext":""},{"type":"reviewerAgreed","content":"243026483228369068893695233865495302928","date":"2026-05-13T20:19:13+00:00","index":69,"fulltext":""},{"type":"reviewerAgreed","content":"29434581034263274136531373126947342997","date":"2026-05-07T18:19:10+00:00","index":48,"fulltext":""},{"type":"reviewersInvited","content":"29","date":"2026-05-05T14:41:34+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T14:54:24+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-20 12:41:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8865683","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8865683","identity":"rs-8865683","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}