Partnerships in global health and development governance have been firmly established as a tool to achieve effective outcomes. Botswana implements Safe Male Circumcision (SMC) for HIV prevention through a North-South partnership comprising the local Ministry of Health, US Centers for Disease Control and Prevention (funded by PEPFAR) and Africa Comprehensive HIV/AIDS Partnership (funded by the Bill and Melinda Gates Foundation). The SMC partnership experienced significant antagony and the aim of this paper is to illuminate the actions and processes in the SMC program that contributed to that antagony.Methods used to gather data include observation of the partners’ planning and strategic meeting in 2012, in-depth interviews with lead officers at national level, focus group discussions with district officers and implementers, younger male officers and old community members as recipients of the service.The findings reveal that the partnership experienced antagony during operational processes and as the ultimate outcome. Target setting, financial power of the North, superficial ownership given to the South, ignoring local traditional realities results in antagony. Three roots of antagony have been identified: 1. therapeutic domination–medical expertise given with arrogance; 2.iatrogenic violence–good intentions that cause unintended harm; 3. the Trojan horse–Reckless acceptance of the gift as well as deceptive power positioned under the pretext of benevolence.The three roots of antagony; therapeutic domination, iatrogenic violence and the Trojan horse, constitute attitudes, hidden intentions and unintended consequences that influence program implementation and cause harm at different levels. Examples of therapeutic domination and the Trojan horse have highlighted the need for vigilance at the stage of establishing a partnership, to prevent more powerful partners from developing and applying hidden agendas and to strengthen accountability from the local partner. Iatrogenic violence has highlighted the need for partnership interventions to prevent good partner intentions accidentally producing bad outcomes. Partnership in global health and development programs has been firmly established as a tool to achieve effective outcomes. It has become a central implementation approach for addressing the world’s complex problems with Sustainable Development Goal (SDG)17 continuing the intentions of Millennium Development Goal (MDG) 8 . The parIn practice, a fundamental assumption is that partnerships can and should produce synergy: successful outcomes far outstripping what any single organisation could achieve on its own . In addiPartnership theory predicts some antagony and suggests mechanisms for managing a partnership to maximise synergy and minimise antagony. Corbin and Mittelmark  used theThe Voluntary Medical Male Circumcision (VMMC) program in Botswana is locally adapted as Safe Male Circumcision (SMC) . The maiAs to the roots of partnership antagony, three concepts that have been advanced in the partnership literature will be highlighted here.therapeutic domination which occurs when the power differentials in the donor-recipient relations are like those in doctor-patient relations, the doctor knowing all and the patient accepting ‘expert’ advice/instruction  only emphasises the sexual enjoyment part…being attractive to women. That is why young men circumcise. They want to be attractive to women and be promiscuous.MOVE advertisements were accused of being insensitive in several ways. Firstly about the male private organ: Traditional leaders suggested that MOVE should not use words like the ‘penis’ when formulating advertisements. Second, there were clashes between the MOVE approaches and traditional initiation protocols. The quotation below, from an elderly man in Mochudi, represents the traditional voice:..You see they do not want to come for SMC. Do not force them. They want to answer to the call for initiation by the chief first.Besides the cultures under study, other communities practicing initiation had a challenge with SMC conflicting with their traditional protocols. The Baherero culture of Boteti communities silently rejected SMC by not participating in it, instead, quietly carrying out their ways of circumcising. The Barolong chief of Goodhope village intensely recruited men for initiation, to oppose SMC requirements that were seen as mystifying the culture. The Ramotswa traditional leadership of the Balete culture abhorred SMC advertisements that MH and DPs made against their will, when they had invited them to circumcise their initiates in the wilderness. There were also complaints about women medical officers conducting the circumcision as well as use of public space like clinics when circumcision was regarded as a secret male rite. Although SMC officers expressed wishes to reconcile mobilisation approaches with community expectations.The MOVE approaches to advertise the program took supremacy.The DPs questioned Government leadership’s commitment and priorities at both national and district level. The national leadership was seen as aloof from the program: not owning it and advocating for it like it did other HIV intervention programs such as Prevention of Mother To Child Transmission (PMTCT). A DP2 officer said:The leadership should give a public face and support to the SMC program but they are not .. they did with PMTCTMeanwhile the national traditional leadership was also not impressed by the misuse of initiation phrases, making public demonstrations against MH for this.MH national leadership was also questioned for not physically placing its regional coordinators closer to their on-ground operational regions (North and South). MH expressed a wish to be trusted on its decisions about coordination of the program. One MH officer reacted to this:This is not the first time I hear this …will you be happy if I tell you how to structure and run your organisation?One DP1 officer explained that their organisation brought in skills to teach government on how to operate partnerships and on higher roles like coordination of the program.DHMT staff commitment was also queried by DPs. They reported that it was their MOVE teams only that were committed to SMC. The quotation below represents how many DHMT staff responded to this:…a sick patient is more crucial to attend to than clients for SMC…We appreciate that the DPs’ MOVE teams can focus on SMC because we have many other duties to do.…but we support them with resources and we help where we can.Antagony around financial power and ownershipAll MH and DP officers acknowledged MH as the owner of the program and a manager for all health activities. However, financial power seemed to define ownership of the program. Partner roles were clear; with MH seen as the owner of the program and DPs as supporting partners. However, there was contention around evidence of ownership. Ownership seemed to be measured by the level of financial contribution. One comment by a DP officer seemed to imply that their level of resource contribution actually made them the owner of the program. The officer said:So if I’m putting more resources than MH on the table but I get not to own the program what am I? They own the program but they are not putting their own resources …I think it has been a very tense relationship between us in the past but I think things have gotten smoother.The same officer said:I really wish the government owned the program truly as their program, not outsource it as the implementation reveals now… The Government of Botswana has not budgeted to achieve this without donor funding.One MH officer explained the government’s stand when this was debated at the three-day meeting: He responded to the query this way:Government budget is about 5 million pula (666 667 USD). This is specifically programmatic funds. Apparently DPs’ funds also cover overhead costs etc, but government has all its overhead costs covered already because it uses its employees, equipment and existing structures. Comparing figures then would confuse.Although the DPs were blamed for not reporting transparently and consistently to MH, the Government of Botswana was responsible for reporting on general financial and implementation performance  to OECD [Organization for Economic Cooperation and Development] regardless of limited information. One MH officer explainedDPs do not tell us everything about their budgets…The Minister has to act like a parent and cover this even though we are not informed about everything concerning DPs budgets distribution…how much they use for capital expenditureIn contrast to taking responsibility like a parent, at times, MH regarded itself as still dependent. For example when donors were threatening to decrease funds one officer used the expression..you cannot wean the baby..Antagony around the targetThe mission of circumcising 80% of HIV negative men in five years, which translated into a target of 100 000 circumcisions a year, became a point of contention as this target was never met in all the years of the program’s existence. There were debates on who set the target and why government agreed to it, yet all entered the partnership aware of the mission and the target. A technical officer from MH explained who set the target:WHO used mathematical models to help Botswana set the target. The questions asked by WHO for the setting of the target were like: how much of the coverage do you need to have impact on protection..? Calculations were made based on the expected impact.The house at the 2012 meeting agreed in unison that the target set for Botswana was unrealistic. The quote below represents voices of all partners:..but the target looks crazy, ..It’s ambitious.The target was brought forward as a major risk of program failure by all 30 participants at the three-day meeting. The house blamed WHO for just using mathematical calculation and not relating that with realities on the ground. They also questioned why Government accepted such high ‘unachievable’ target. One DP2 officer said:Is Botswana being realistic? From the word go, we have already been sent to fail before we start. We are now at 14.7% of the target we hope to achieve by 2016. What are we saying?Another DP1 officer added:Botswana government accepted the target. And it’s a self-fulfilling prophecy in my opinion because you agreed to the target which you are never going to attain.There is inconsistency between public demand for SMC and the supply of equipment. Although the target was hard to reach, DP1 still brought in circumcision surgical kits from pharmaceutical companies abroad. It was reported that close to 100 000 kits were received but less than 40 000 were used. Government health centers were blamed for underutilization and misuse of the kits as the balance sheet reflected.It seemed pressure to meet target was experienced more by the DPs while MH preferred long term program development within its health system. One MH officer explained:You see with government, it is about ensuring that the service is permanently established within the government system. The DPs are experiencing pressure to meet donor expectations. So.. we understand their frustrations. MH also strives to meet the target but the most important thing is long term establishment of the program.During the 2014 round of interviews, several officers reported that MH and partners had taken a decision to cut down the target to circumcising 50 000 instead of 100 000 men per year. However they also expressed fear that by lowering the target it conflicted with the WHO recommended target and expected impact on infection rate. One MH officer explained this dilemma:We have cut down the target to 50 000. It is realistic to us given the circumstances, but it will not help us meet the 80% infection reduction rate… We will have to explain this to WHO. Their 100 000 target still has not changed.At the time the target was revisited in 2014, the DPs had already started reducing their financial contribution to the program. One DP1 officer explained:DP2 is now chipping in 25% of the 100,000 target per year at the moment instead of 40% as it was initially. We were also hoping to chip in 25% or more but we have to cut it to 15% just basing on reality. Our donors are not happy about the low numbers. They have cut down funds…Donors ceased their participation in the program between mid-2014 and 2015. After the donors pulled away only one officer was able to give us access for further interview. Whereas MH explained the pulling away of the DPs with a sense of empathy there was at the same time, an expression of despair within the MH. The MH officer said:They have pulled out at a very wrong time. In fact, it is a loss on our side. It was unfortunate because there was no consultation when they were deciding to pull out. They just notified us in less than a month to say all the support from DP1 to Botswana SMC will be terminated. So, most of the contracted partners that we had that were funded by DP1 are no more.The officer explained that he pulling away of DP1 hit MH hard.…because they were becoming agitated that they were spending a lot of money but the results were not coming, so they pulled out. DP1 is America itself… …Obviously this has already shaken us. When they pull out they withdrew a promise of billions of US Dollars. Where will we get that money? DP1 had contracted many other partners. So they are goneLast year we lost DP1 that was supporting the bulk of the program.The MH officer explained that they were experiencing the gap left by DPs’ medical teams and that the government could not manage the gap at that time, therefore men seeking SMC service at the dedicated clinics were leaving without being helped. After the partners pulled away MH planned to continue the integration program. They planned to revisit their implementation strategy and involve the community more so that the community approaches could be used to recruit men.Attempts to analyse data using the three chosen theoretical concepts; therapeutic domination, iatrogenic violence and the Trojan horse proved to be complex. Examples of each concept can hardly be represented by a single quotation but is seen throughout the four global themes in the findings. The antagonistic outcome is also rooted in the three concepts. Below we demonstrate the entanglement of the three using two themes, MOVE and the community. Our two themes represent two levels of interaction: Interaction between MH and the DPs and interaction between the partnership and the communities.therapeutic domination by the North. Designed and created by WHO and adopted by PEPFAR, it carried with it the arrogance of knowing best. The approach of the Global North dominated over the local integration approach, over the culture and traditional views on how things should work. However, the government of Botswana allowed the DPs to take the initiative and lead the MOVE activities. Botswana’s relaxed attitude and DPs domination created community resistance. Regardless of the resistance, and without seeking to learn from antagonistic tensions with communities, external approaches continued to dominate. When expectations were not met, partners pulled away. The North disregarded the responses from the local communities and did not even revisit its approach. Although the need to listen to local communities’ views was discussed in meetings as important, it was never made a priority. The MOVE has in it iatrogenic violence. We observe that it was brought in intended to do good. But when things went wrong–like the purchase (by partners) and waste of equipment–MH had to take responsibility. Likewise when the partners pulled out MH was left with the responsibility of equipping and managing the dedicated SMC clinics that had been set up. This is an act of a doctor starting medication and then withdrawing it—bringing harm instead of healing. The MOVE project was also a Trojan horse, a false ‘gift’ from the North presented as a solution to push the set target to circumcise 100 000 HIV-negative men in a year in Botswana. MH was happy to receive it since its ideas and strategies appeared good on the surface. However a closer look reveals that MOVE ‘carried hidden destructive motives’: of acting powerful and side-lining the indigenous approach–integration; operating as a separate entity and creating dependency instead of building on the Botswana health system that exist to improve it; pulling away and leaving MH with no resources. The irony here is that MH accepted the “gift” and even contributed to the partnership. The DPs are more tied to donor driven expectations regarding outputs than the ministry of health.Therefore MH could be held accountable for not standing strong to ensure that the voice of the community is heard and that integration of services as well as the desired indigenous approaches are followed.The MOVE, of itself, is an act of therapeutic domination from the SMC program. In fact, even beyond a lack of respect for their values, their social and cultural customs were disturbed, for example through the use of women conducting the circumcision operations. This disruption represents iatrogenic violence which was exacerbated by the introduction of MOVE. In response to resistance by the chiefs, MOVE sought ways to recruit men and boys without the chief’s support, for example by campaigning in schools or with a popstar ‘ambassador’, thus finding a way in behind the community defences–just like the Trojan horse.The SMC program promoted medical circumcision as ‘better’ than traditional circumcision within initiation. Communities were expected to integrate SMC into their traditional practices but the views of communities were neither listened to nor their values respected–especially regarding circumcision within initiation. The community experienced This paper has explored different roots of the antagony experienced within the SMC partnership in Botswana. Antagony around finances, leadership and ownership, the local and international approach to implementation, community’s responses regarding the MOVE’s biomedical marketing approaches, are all a reflection of the behaviour of the North on health partnerships. We use Fowler’s  and McFaPartnership implies an equal, respectful collaboration in achieving a common goal, but the inequalities in roles and status of the partners caused tension and confusion. The MOVE approach carried with it Northern domination and control, proving to be powerful while diminishing local approaches and the local partner. The MH seemed to have uncertainty concerning its position as the owner of the program, and its ownership was also questioned and doubted by the DPs. The MH presented itself with three metaphorical descriptions at different times: as the owner, the parent and the baby. In view of itself as the host, beneficiary and health systems manager MH claimed the position of the “the owner.” It also called itself “the parent” or “parental state” that signed the agreement with WHO and has the obligationto report country performance and financial stand to OECD. The irony is that it did not know all the financial undertakings of the DPs since transparency was limited. When the DPs were threatening to pull out it claimed the position of a “baby that should not be weaned.” In contrast, the development partners gave Botswana the title of “owner” yet labelled it as slow to push its own target; they accused MH of professing ownership yet not acting as owner. Also, the highest leadership of the country was criticised for not supporting the program as its “face.” Therapeutic domination by donors gives ambiguous roles to the local partner, calling them “owners” of the program, but treating them as less-able recipients who should follow rather than lead , 44, 45.In practice ownership was demonstrated through financial power. Financial resources, implementation speed and the social marketing approach made the international partners seemingly more efficient as they effectively took control of the implementation, mystifying the ownership of the program. However government health workers were also overwhelmed with other duties and had little space for SMC. The development partners insisted to know MH’s financial contribution, hardly giving acknowledgment to MH’s contribution of infrastructure and human capital. Instead, they viewed themselves as doing better than MH on financial contribution, yet without being called “the owners”.There is another contra observation in this partnership: Although in practice, ownership was demonstrated through financial power, the balance of power here seems more delicate than financial contribution. MH had given in-kind contribution through infrastructure, human resources, supply chains, policy and overheads. Therefore, instead of being powerless against the DPs and donors, the MH shifted the burden of SMC scale-up (and particularly MOVE) both in terms of finances and other resources on to DPs. Alden and Schoeman  argue thPartnership intends to do good and to produce harmonious results but in this case it also caused unintended harm. Iatrogenic violence was experienced at different levels . The sevPartnership implies transparent collaboration to achieve a common mission but in SMC the agenda of the Northern partners seems hidden in the term ‘partnerships.’ The North is accused of having a hidden agenda to control, of practicing foreign penetration and imposing power . Fowler In this partnership, MH’s approach of SMC integration into the national health systemwas “overpowered” by donors’ technocratic accountability mode of dollar-to-numbers that brought in the “MOVE project to push numbers towards set targets” as one DP2 officer explained. The MOVE project brought in American values–the approach of biomedical marketing that targets individuals, as opposed to the collective approach preferred by the communities receiving the service . ForeignThe MH is not blameless. The Southern partners’ are responsible to ensure that their voice is heard and not silenced by their lack of financial power and expertise . The MH’The nature of antagony in the SMC program in Botswana has implications for North-South health partnerships theory and practice. As to theory development, the findings of this study suggest roots of antagony that partnership planners and managers should be alert to. As to practice, evidence for iatrogenic violence has highlighted the need for partnership interventions to prevent partners’ good intentions accidentally producing bad outcomes. The metaphors of the Trojan horse and therapeutic domination have highlighted the need for vigilance and rigour at the stage of establishing a partnership, for the local partners to take responsibility and prevent more powerful partners from developing and taking over local implementation. As an appeal, researchers should consider exploring measurement of antagony in partnerships just as they have done for synergy.It is acknowledged that the purposive selection of participants may not represent all views in the larger community of Botswana. Although the research covered a variety of participants, most data used in this paper come from the national and district officers and other data were used to validate their statements and observations. Voices of young men from the communities were not represented in this paper. The other limitation is that the voice of donors is not heard since donors were not interviewed. Although this paper may be used as a learning resource, the exploratory nature of this study makes it impossible to generalise the findings.It is unclear from this analysis what might distinguish countries that experience less antagony and make the partnership work better, and those countries that experience antagony that affects the partnership more severely. An independent in-depth on this will contribute to showing what it means for partnerships going forward, not only in Botswana but in the rest of the region.Therapeutic domination–expertise given with arrogance–was shown in prioritising external approaches such as the MOVE project which was more concerned about numbers than other implementation realities, side-lining the local Government’s approach of integration. The DP’s lack of acknowledgment for MH’s non-financial contribution indicated their belief in the superiority of their modes of involvement. Iatrogenic violence–good intentions that cause unintended harm–was evident when MH was left with the sole financial and operational responsibility for all aspects of the program once the DPs pulled out. The Trojan horse–deceptive power positioned under the pretext of benevolence–is illustrated by the MOVE approach that brought false hope of victory but was a vehicle for donor control. Receiving the gift and then blaming the giver is a sign of weakness of the South. These underlying attitudes, approaches and intentions all contributed antagony to the SMC partnership in Botswana.This paper has explored different types r of antagony and their roots. Target setting, the financial power of the North, superficial ownership given the South, ignoring local traditional realities resulted in antagony. In spite of the rhetoric of partnerships, the continued domination of the northern partners has been illustrated by three concepts that influence the outcome of the partnership. S1 File(PDF)Click here for additional data file.


Translating evidence-based interventions from study conditions to actual practice necessarily requires adaptation. We implemented an evidence-based Hospital at Home (HaH) intervention and evaluated whether adaptations could avoid diminished benefit from “voltage drop” (decreased benefit when interventions are applied under more heterogeneous conditions than existing in studies) or “program drift.” (decreased benefit arising from deviations from study protocols).Patients were enrolled in HaH over a 6-month pilot period followed by nine quarters of implementation activity. The program retained core components of the original evidence-based HaH model, but adaptations were made at inception and throughout the implementation. These adaptations were coded as to who made them, what was modified, for whom the adaptations were made, and the nature of the adaptations. We collected information on length of stay (LOS), 30-day readmissions and emergency department (ED) visits, escalations to the hospital, and patient ratings of care. Outcomes were assessed by quarter of admission. Selected outcomes were tracked and fed back to the program leadership. We used logistic or linear regression with an independent variable included for the numerical quarter of enrollment after the initial 6-month pilot phase. Models controlled for season and for patient characteristics.p = 0.03), but no effect was observed for LOS , 30 day ED visit , 30-day readmission , or patient rating of overall hospital care .Adaptations were made throughout the implementation period. The nature of adaptations was most commonly to add or to substitute new program elements. HaH services substituting for a hospital stay were received by 295 patients . A small effect of quarter from program inception was seen for escalations  definition because it is an observational study “in which the assignment of the medical intervention is not at the discretion of the investigator.”The online version of this article (10.1186/s12913-019-4063-8) contains supplementary material, which is available to authorized users. Translating complex multi-component evidence-based interventions from study conditions and protocols to actual practice necessarily requires minor to major adaptation of intervention content, format, personnel roles and processes. Adaptations may be desired or necessary to customize to local circumstances or to account for new technology or temporal changes in disease epidemiology or clinical practice , 2. Trad3, thereby neutralizing any diminished effectiveness from program drift or voltage drop or perhaps even increasing the net benefit beyond that observed in evidence-based studies. Other adaptations may inadvertently diminish benefits. Indeed, some have called for the systematic study of adaptations to evidence-based interventions and a formalized structure for updating the evidence base to account for adaptation [More recently, the inevitability of diminished benefits due to program drift and voltage drop has been questioned. While fidelity to a study population, setting, and protocol may be critical for a biological or a clinical intervention to maintain the studied benefits, this may not be the case for health system interventions or more complex multi-component interventions. Adaptations may be made as the intervention is applied in more heterogenous patient populations or practice settings, thereby potentiating voltage drop. Other adaptations may be made to the intervention protocol to improve fit with the practice setting and the environment, thereby potentiating program drift. Other adaptations may address technological or medical advances that were not available or formally manualized at the time of the evidence-based study. In theory, these adaptations may have neutral effects. Some adaptations may enhance the effectiveness of the original interventionaptation .To improve our understanding of the effect of adaptations, we took advantage of an implementation of an evidence-based hospital admission avoidance Hospital at Home (HaH) intervention . This imFunded as an innovation award from the Center for Medicare and Medicaid Innovation, this implementation of HaH was instigated with the goal of eventual sustainment in the local health system and scaling and dissemination nationally. The phased plan for implementation within the local health system was consistent with the concepts outlined in the Dynamic Sustainability Framework (DSF) . The DSFPatients were enrolled in HaH starting in November 2014 for 33 months through August 2017. An initial 6-month run-in pilot period was followed by nine quarters of implementation activity.Details of HaH patient engagement procedures have been reported elsewhere . BrieflyPatients were eligible for HaH if they were ≥ 18 years of age, required inpatient admission, and had fee-for-service Medicare or coverage from a single private insurer that contracted with Mount Sinai for HaH services. Patients were excluded if they were clinically unstable , required cardiac monitoring or intensive care, lived in an unsafe home environment, or resided outside the specified catchment area.The HaH program retained many of the core components of original evidence-based studies of HaH . As described later in the list of adaptations made to the HaH program, HaH service lines evolved to include palliative care at home, observation unit at home, and rehabilitation at home  . We also exclude patients who received observation services for a single overnight period (n = 41). If hospital services were extended overnight past a second midnight for patients initially admitted to observation services, we considered the case to have been converted into a regular HaH stay and include them in our analyses; this simulates what would have happened if a patient had been admitted to a regular hospital observation unit and required services past the second midnight. Patients receiving palliative care services at home were receiving HaH for what substitutes as a hospital stay and are included as well. After exclusions, our sample includes data on 295 patients.Because the outcomes collected were most relevant to hospital stays, we report outcomes for patients admitted to the program where the intervention was used to substitute for a hospital stay. That is, we excluded patients receiving rehabilitation at home (We present outcomes by quarter of HaH patient admission. We used logistic or linear regression (in the case of LOS) with an independent variable included for the numerical quarter of enrollment after an initial 6-month pilot phase. We estimated the average marginal effect for number of quarters since the program began  for LOS. Odds ratios were estimated for the other models. The models controlled for season of HaH admission, patient age, sex, race, ethnicity, education, insurance type, functional impairment, and self-rated health.n = 64), physical function (n = 115), and general health (n = 84). To maximize the number of patients in the models, we used multiple imputation, modeling the probability of missing data for each variable on age, sex, race and ethnicity, education, insurance type, pre-acute physical function, and general health. Analyses were performed with SAS version 9.3 .More than 10% of data were missing for race and ethnicity  review and patient consent was not required. We requested and received approval from our IRB to conduct a retrospective analysis of these data.Over the 33 months of implementation, a series of program adaptations were implemented . The odds ratios (OR) per quarter from program inception was mildly increased for escalations , but was not increased or decreased for 30 day ED visit , 30-day readmission , and the patient providing the highest rating for overall hospital care .In the regressions, we did not observe a relationship between quarter from program inception and LOS  and vendors . We believe that the need and opportunity for dynamic adaptation occurs to varying degrees in the implementation of all new programs and is not limited to the HaH implementation experience we chart in this paper .We modified the protocols used in our HaH program from the existing research evidence base described in the literature. For example, the addition of new diagnoses, alteration of clinical exclusions, and the addition of 30-day postacute follow up were changes from studied protocols. Despite this, for selected findings of LOS and patient satisfaction, our outcomes were similar to those reported in the original studies in Table Additionally, we made adaptations in which we modified the HaH approach to changing context each quarter. For example, we added palliative care and other programs, as well as telehealth and community paramedicine visits. However, we did not observe significant changes in effectiveness across a variety of measures. LOS, 30-day readmissions, ED visits, and patient ratings of care did not significantly change over time. Tracking and reviewing these outcomes on a monthly basis as part of a continuous improvement activity may have been important in maintaining these effects through the implementation period. In the case of escalations, we observed a trend toward higher rates in later quarters. This was expected as our clinicians purposely started the program with less complex patients and enrolled increasingly complex patients as the team gained experience. The escalation rate was actually closely monitored throughout implementation, the program team was conscious of the trend, and cases of escalation were reviewed by the team on an ongoing basis in the interest of continuous improvement. Thus, we believe that the implementation of serial adaptations may have also avoided the phenomenon of “voltage drop.”Our study was limited by sample size by quarter. There are also occasional quarters where readmissions or other outcomes appear to increase. However, these occurrences are transient and the trend over the nine quarters is one of no change. A further limitation is that individual adaptations could be hypothesized to potentially enhance or diminish net benefits or program efficiency. For example, the community paramedicine intervention was intended to improve response time, enhance ability to adjust treatments in the home, and to reduce trips to the ED. One could hypothesize that this might enhance effectiveness. On the other hand, observation services at home were a departure from the evidence-based model, and one could hypothesize that these patients might be less likely to benefit. Because adaptations were made as the need or opportunity arose, it is not possible for us to isolate and examine the effect of any individual adaptation in this analysis.The implementation of evidence-based programs necessarily requires adaptation. We made significant adaptations to HaH at inception and then serial adaptations over the course of implementation. Over the course of the implementation, many of these important outcomes were tracked and fed back to the program leadership leading to further adaptations. Our findings may indicate that adaptations to evidence-based programs may avoid diminished benefits due to potential ‘program drift’ or ‘voltage drop’.Additional file 1:Hospital at Home Baseline Survey . (DOCX 20 kb)Additional file 2:Hospital at Home Two-Week Survey . (DOCX 29 kb)Additional file 3:Hospital at Home Four-Week Survey . (DOCX 18 kb)Additional file 4:Regression models controlling for patient characteristics and season of admission mentioned in page 12. (DOCX 16 kb)


Implementing programs such as R3, which adds health-focused supportive services into senior housing sites, can be complicated. This study aimed to understand program management and wellness team views on barriers and facilitators to implementation. Semi-structured interviews were conducted with managers, social workers, and wellness nurses who implemented the R3 program. Facilitating factors included monthly phone calls between wellness team members and program participants, which strengthened relationships and provided valuable information; top-level management support, which was critical in building community partnerships; and daily ambulance reports from local emergency responders, which provided actionable information about participants. Barriers included the need for more wellness team time at individual intervention sites, challenges connecting R3 staff with participants’ hospitals and insurance companies, and refining the technological approach used to facilitate work flow and information exchange. Although obstacles were encountered during implementation, the findings provide support for the beneficial effects of enhanced services within senior housing.


Within Canada, several specialized multi-service prevention programs work with highly vulnerable pregnant and early parenting women with substance use issues. Experiences of trauma, mental health, poverty, and other factors associated with the social determinants of health complete the picture. Program evaluations have demonstrated their value, but less has been said as to women’s reasons for choosing to seek help from these programs, what they were hoping to gain, or what difference they believe has occurred as a result. The Co-creating Evidence project is a multi-year (2017–2020) national evaluation of holistic programs serving women at high risk of having an infant with prenatal alcohol or substance exposure. The evaluation uses a mixed methods design involving quarterly program output and “snapshot” client data, as well as in-person, semi-structured interviews and questionnaires with clients, program staff, and program partners. This article presents findings from interviews with women regarding why they sought help, how they used the services, and what they perceived to be the most significant change in their lives as a result. Obtaining help with substance use was the top theme for what women hoped to get from their participation in their program; however, women’s reasons were often intertwined. Additional motivations included wanting information, support or assistance with: child welfare; pregnancy; housing; getting connected to health care or prenatal care; and opportunities for peer support. With respect to the most significant life change, themes included: reduced substance use; improved housing; stronger mother–child connection; and improved wellness and social connections. Findings demonstrated that vulnerable, marginalized pregnant and parenting women who are using substances will seek help when health and social care services are configured in such a way as to take into consideration and address their unique roles, responsibilities, and realities. Prenatal consumption of alcohol and drugs continues to be a major health, social, and public policy issue in Canada ,2. IndeeWomen’s reasons for prenatal substance use are both complex and gendered. Research suggests that women’s prenatal substance use is often driven by a host of social determinants of health factors such as deep poverty, a history of physical or sexual abuse and neglect or other forms of trauma, intimate partner violence, mental health concerns, precarious living conditions including homelessness, child welfare involvement including maternal–child separation, and physical health problems ,6,7,8. MSystemic barriers compound the situation as standard systems of care often don’t meet the needs of women with prenatal or postnatal substance use issues, especially not women trying to raise children. Indeed, substance use and child protection services tend to operate in discrete silos with their own distinct goals, policies, expectations, and legislative responsibilities that in the past have resulted in high rates of child apprehensions from families wherein parental alcohol and drug use is a factor ,12,13,14As a result, when seeking help for their substance use, vulnerable, marginalized women commonly experience numerous barriers including: stigmatization, lack of mental health supports, negative attitudes of health care providers, and adversarial approach of child welfare authorities ,9,10,15.Despite these hurdles, for many vulnerable women, pregnancy is a time of increased motivation to contemplate significant life changes, particularly prompted by women’s desire to keep their newborn in their care . Indeed,Research indicates that many women who use substances during pregnancy are polysubstance-using ,4; furthDespite the evidence that exists with respect to promising approaches, further study would help to enhance our understanding of their implementation in community settings, including a better understanding of what motivates clients to seek services and supports as well as their perspectives on what changed the most in their lives as a result of their involvement in the service(s). To address this, a multi-site evaluation of “wrap-around” FASD prevention programs serving women at risk was envisaged.In keeping with the internationally recognized four-part FASD prevention model , women aSummary descriptions of the programs taking part in the study are provided in Box 1HerWay Home (Victoria BC) offers drop-in and outreach support, on-site wellness and prenatal/post-natal groups as well as other health/medical services for women and their children, through a combination of program staff and in-kind support from the Island Health Authority. Women can participate in HWH until their child is approximately three years old.Sheway (Vancouver BC) is a partnership between Vancouver Coastal Health Authority, Ministry for Children and Family Development, Vancouver Native Health Society and the YWCA of Vancouver. A range of on-site health and social services is offered on the first floor; an on-site health clinic is on the second floor; and child care and housing operated by the YWCA is on the third floor. Voluntary child welfare services are provided on-site through a partnership agreement with the provincial Ministry. The length of time that women can participate in Sheway is flexible and not set by the child’s age.Maxxine Wright (Surrey BC) offers health and social supports through co-location with Atira Women’s Resource Society, which operates transition housing and second stage housing on-site. Atira offers most of the social programming, with participation from Fraser Health. Health/medical care is provided by Fraser Health. Child welfare and income assistance services are provided on-site through a partnership agreement with relevant provincial Ministries. Women can participate in MW until their child enters school.Healthy, Empowered, and Resilient (Edmonton AB) is located within the Boyle Street Community Services, which provides an array of social, mental health, family, and cultural services in Edmonton’s downtown core. H.E.R. provides outreach to highly street-involved clients; through its staffing and partnership with Boyle McCauley Health Centre, H.E.R. clients have access to prenatal care and post-natal support. Women can participate in H.E.R. until six months post-partum.Raising Hope (Regina SK) is a residential program located in an 18-unit apartment building (purchased by a non-profit housing society for the program’s exclusive use). A range of health/medical, social/cultural supports and programming including child care is offered on-site; residents are required to take part in daily programming. Women and their children can stay for 18 months.The Mothering Project (Winnipeg MB) is a program of Mt Carmel Clinic and is co-located with the clinic. Through its staffing and partnerships, the MP offers a broad range of drop-in, outreach, and on-site supports and health/medical services along with a dedicated space for cultural ceremony. A licensed day care is co-located with MP with spaces set aside for program clients. Women can participate in the MP until their child reaches the age of five.Breaking the Cycle (Toronto ON) is one of the first FASD prevention programs in Canada. The program provides children’s developmental assessment and mental health services with wrap-around services for women. Each woman is connected to a counsellor and each child is connected to a Child Development Worker. Women can participate in BTC until their child is six years old.Baby Basics (New Glasgow NS) is a weekly drop-in parenting program operated by Kids First Family Resource Program, for women under age 25 and their children age 0–6. Although not specifically directed at women who are using substances, there are very few such options available to women in the region. BB offers a safe place for women to access support and talk about a range of issues. Women can participate in BB until their infant is one year old.What women hoped to get from engaging in their program;How women used their program’s services/activities; andThe most significant changes that women experienced as a result of their program.A previous article  describeThe co-creating evidence study is employing a mixed-methods design, guided by principles of collaboration and partnership. The study is guided by collaborative and participatory principles , includiThe project team is undertaking two visits with each site, to conduct face-to-face, semi-structured, qualitative interviews, focus groups and questionnaires with staff, clients, and program partners.The program manager/coordinator at each site is compiling and remitting quantitative output data and client-based data from April 2018 to September 2019, for a total of 18 months.Data are gathered through two separate processes:This article focuses on the qualitative interviews conducted with clients/participants during the first site visits between April and July 2018 and questionnaire data collected as part of the interview process. It is supplemented with interview data with staff and program managers/leaders.The project team conducted individual qualitative interviews with clients, using an interview guide that was created for this project. Interview questions include: how the woman first learned about the program; what she hoped to get out of her involvement with the program; her life situation just prior to becoming involved with the program; her satisfaction with the program ; and what was most important to her about the program. As well, the interview contained open-ended questions pertaining to the client’s use of the program’s various services and activities. Clients were also asked about perceived impacts of the program. A modified version of the most significant change (MSC) technique was employed ; informaAfter the interview, women were invited to complete the client questionnaire, which most often was administered verbally by the project team member, but which the participant could complete on her own if she preferred. The client questionnaire utilized a five-point Likert-type scale and focused both on participants’ experiences with their program , and their perspectives on program impacts and how helpful the program had been in relation to outcomes in various facets of their life  in their care, and quitting or reducing their substance use). The questionnaire was created specifically for this study; at the same time, it included standardized questionnaire items that have been used in evaluations of trauma-informed and/or harm reduction focused programs .All participants were provided with an honorarium ($25) for completing the interview and questionnaire. Program staff were available afterwards should clients have questions, comments, or concerns regarding the interview. Prior to launching the formal data collection, the project team pilot tested the interview guides and interview process with four sites. The purpose was to garner feedback from clients and staff regarding the process and the questions including how clients felt about answering potentially difficult questions about their lives.Eligibility criteria for client participation in the interview and questionnaire were as follows: (a) the woman had to be accessing services from the program in the month of data collection; (b) women were 16 years or older; and, (c) women were English-speaking. Recruitment was handled by program staff who, approximately one month prior to the site visit, posted notices in program space regarding the interviews and made announcements during group and/or drop-in programming, inviting clients to come to the program for an interview or otherwise express their desire to do the interview off-site. Both forms of recruitment reinforced that the interviews were confidential and anonymous. For clients, a voluntary sampling approach was employed as program coordinators and the research team thought it was important for all clients who wanted to take part in an interview and who were available during the team’s site visit to be able to do so. At the same time, program staff did not formally track the number of clients whom they told about the site visit and interview opportunity, nor did they keep track of the number of clients who expressed disinterest in doing an interview; thus, it was not possible to know how many, if any, clients refused to participate in the in-person data collection process. A nominated sampling approach was used to create the sample of service partners; program staff at all sites provided the researchers with contact information for each program’s closest service partners.n = 32 at one of the largest sites to n = 8 at two sites; there were three sites at which more than 20 clients were interviewed and five sites at which 8–11 women were interviewed. Differences in terms of the number of interviews conducted per site reflect the size and scale of the programs and was roughly proportional to the number of clients per site. As well, events outside of the program, including crises in the community and/or in clients’ lives also impacted response to the invitation to take part in the study.A total of 125 program participants/clients (of whom 123 completed the client questionnaire) took part in an in-person interview between April and July 2018. The number of interviews with clients varied across sites, from All of the program participants identified their gender as female, and more than half were older than 30 years old see . Every pn = 0 to n = 45, and percentages reported in the results did not include the women who did not answer each question in the denominator.A frequency analysis of the client questionnaire was conducted in SPSS 26  to describe the participants. Missing data for each question ranged from As the interviews with clients, staff and service partners involved open-ended questions, qualitative data analysis techniques were used, and qualitative data analysis software (NVivo12)  was utilized to facilitate the analyses. In keeping with these techniques, written transcripts from all interviews were read multiple times by the researchers to begin the process of identifying themes and analytic ideas. Initially, each researcher coded the transcripts separately and identified preliminary themes inductively. The three researchers involved in carrying out the interviews highlighted naturally occurring patterns in the data, including words, phrases, or ideas most commonly voiced by participants, which formed the basis of the thematic analysis ,36. As mThe evaluation study received ethics approval from the University of British Columbia Office of Research Ethics (H17-02168), Fraser Health Authority, Vancouver Coastal Health Authority, Island Health Authority, and York University. Study participants provided informed consent to participate in the interviews. All study participants were competent to provide their own informed consent and all were over age 18.Drawing on interviews with staff and program leaders/managers and written program descriptions, Wanted support in relation to problematic substance use and/or traumaWanted support with child welfare and/or mother–child connectionWanted support and information related to pregnancyWanted help in getting housingWanted help in getting connected to health care or prenatal careWanted healthy peer connections or peer supportBrief discussion of the key themes follows.Clients were asked what they had hoped to get by participating in their program. The themes were often interconnected, as clients generally provided several reasons for program involvement. The top themes to emerge were (in order of frequency):I wanted to get sober. I wanted my children back, my family back. …. I was using drugs and alcohol. I was going through a rough time—breaking up with my partner who was abusive mentally and emotionally.[I wanted] better housing, support to keep me away from drugs and alcohol, and help with nutrition. [I wanted] to keep my baby.[I wanted] connections with other mothers and knowing that there were groups I could do that would help me with being a mother with trauma and addiction.The most frequently emerging theme—voiced by nearly half of the clients interviewed—was that women were seeking help in addressing their substance use. However, for many women, this was intertwined with wanting help in dealing with effects of trauma because of experiences of violence or abuse and with wanting help with housing and with child welfare issues. (Child protection/child welfare terms are used interchangeably. Provinces/territories within Canada hold the legislated mandate to protect children and if need be to remove them from their parent(s). Generally speaking child protection social workers investigate and will remove children if deemed necessary, whereas child welfare social workers are tasked with working with the family to mitigate the risk factors. Nevertheless, any involvement of child protection/child welfare authorities means that the parent(s) is/are under scrutiny, that risk factors or concerns are present and that the parent(s) could lose their child if they are unable to satisfy the expectations of child welfare/child protection staff.)I wanted a different way of bonding with my child, a different community.I wanted connections with other mothers and knowing that there were groups I could do that would help me with being a mother with trauma and addiction.I wanted sobriety and to learn to parent my kids; I had lost custody.I wanted to get support and bring my child home and parent in a healthy lifestyle for her and for me.Hand in hand with women’s desire for support in relation to their substance use was their desire for support in relation to keeping or regaining their child(ren) in their care and/or in having a strong mother–child connection. Clients often sought participation in specific program activities  and/or sought connection with program staff who would be able to speak to their motivation and capacity to care for their child(ren); most often, the programs were already known to clients for their support and advocacy in relation to child welfare.To start with, I only wanted to get my children back. Now I want a better quality of life for me and my kids.I also wanted to connect with a therapist. I wanted to have a stable foundation to work with. I knew [child protection] would be involved, so I wanted to create a healthy foundation for that involvement.While wanting to demonstrate that they were capable of parenting may have been the initial impetus for attending their program, as women made gains, some realized that they wanted more, whether that was a better quality of life or a more stable foundation for building a life for their children.I was pregnant and had addictions and I wanted to have support through my pregnancy.Initially, I didn’t know where or how I’d go with the pregnancy. I needed guidance and support. When I first found out I was pregnant, I cried for 48 hours straight. I also wanted information. I didn’t know where to go and what my next step would be.Support to keep moving forward. I wanted to make changes in my life.Another strong theme and reason for engagement with their program was a desire for guidance and information in relation to their pregnancy as well as help with other issues such as finding safe and stable housing, child welfare, and substance use. Many women spoke of wanting this pregnancy to be different from their previous one(s).Support, because I have [child protection] involvement. I wanted support and stable housing and getting addictions out of the way. I want to go home with my baby.I was in a really shitty situation. I was living with a friend; she was using drugs. I ended up in a shelter. I needed resources to help me with my pregnancy and with raising my baby, and I wanted help getting into different housing.As noted previously, at intake over half of clients (ranging up to 85% at some program sites) had precarious and/or inadequate housing. Clients voiced their desire for program assistance in helping them access safe and stable housing, as they also recognized the inextricable connection between housing and child welfare authorities’ safety concerns.My family doctor set me up with a maternity doctor who specialized in working with women with addictions. She suggested that I network with someone. I was afraid that the nurses at the hospital would see my medical history, see that I was on suboxone, and be judgmental and call child welfare.I was looking for prenatal care. I was looking for programs and people to help support me to have a healthy pregnancy.Approximately 20% of the clients interviewed stated that they were looking for health or prenatal care. Some women sought a health/prenatal care provider because they had recently moved to the community—often to flee an abusive ex-partner or to shed ties with people who used substances—while others may have been in the community for a while but sought a prenatal care provider in order to focus on having a healthy pregnancy. As well, some women emphasized that they wanted to connect with a health or perinatal care provider who would not judge or stigmatize them for their substance use.I was looking for support and advocacy for my situation. I was needing a group for women like me who have been through years of trauma and abuse. I did not want to be the only woman in the room with that kind of lived experience.[I wanted] to open up more; learn how to speak to others when they needed help; to share my story with others who were struggling; to help guide others on a positive path.Finally, wrapped up in the notion of finding support was a desire by clients for healthy peer connections, partly born of a desire to be amongst women with similar backgrounds and with whom they could safely share their story.The sense of community here. Support group. I didn’t know other pregnant women.Some women wanted the sense of community that could come from being in a prenatal group and to have answers to their questions.As part of the qualitative interviews, clients were asked to describe ways in which they used the various activities or services offered by programs. A sample of their comments, presented in Quit or reduced substance use;Strengthened mother–child connection;Kept/regained custody/care of child(ren);Improved wellness/mental health;Increased support;Safer, improved housing.As a key component of the qualitative interview, clients were asked what had been the most significant change(s) that had taken place for them and their family since they started participating in their program. As was the case with other open-ended interview questions, women’s responses often contained multiple themes, and the themes were clearly intertwined. The top themes were (reported in order of frequency):n = 51), was that they had quit or reduced their substance use. Many attributed their program with helping them to quit using substances.If I hadn’t been at this program, it would have been harder to stay sober, and my baby would have gone to live with my mom.Because the staff care so much about their clients, I’ve gotten clean. I’ve been in and out of addiction for 18 years, but because of them, my using time has reduced—it’s down to two days. They’ve reached out to me. They’ve made a huge difference to me.The most frequently emerging theme of the “most significant change,” voiced by approximately 40% of the clients interviewed  agreed or strongly agreed that the program had helped them quit, reduce or engage in safer substance use, and 70%  agreed or strongly agreed that the program had helped them access substance use services or supports. Approximately 20% of women indicated on the client questionnaire that these items were not applicable to them, as they had not sought help from their program for substance use concerns.In keeping with these findings, on the client questionnaire, 79% (n = 49), pertained to the existence or strengthening of the connection between the woman and her child(ren). This important theme focused on the presence and preservation of the mother–child relationship rather than on whether women had retained or regained custody of their child(ren), and thus it was voiced both by women who did not have their child(ren) in their care as well as those who did. Similarly, most women  agreed or strongly agreed on the questionnaire that the program had helped them improve their connection to their children. This theme also relates to the situation voiced by some women that, had they not had support from their program, they likely would not have continued with their pregnancy:My baby and I have a home. We know we’re not alone—both because I can call the [program] staff and because of other women. Without [program], I probably wouldn’t have had my baby.My stress level has gone down quite a bit. I know that no matter what, they’ll be here. The program helps with everything: prenatal care, housing, [child protection] advocacy, baby stuff. Before coming into this program, I felt hopeless.The second theme, voiced by nearly the same number of clients , had to do with women’s experience of improved wellness and well-being. Along these lines, clients described feeling happier, less stressed, more self-confident, self-aware and emotionally equipped to deal with personal triggers, as well as being more socially engaged.Our household is more balanced. I know my triggers and deal with anger better. I am more balanced emotionally.Coming to [the program] is getting us out of our shells. My daughter and I, we really needed this. It’s really made a difference in terms of our health, mental health and well-beingThe fourth top theme, voiced by about a third of the clients interviewed  agreed or strongly agreed with the statement “I feel supported and less isolated; I have social support.”Paralleling these findings, on the client questionnaire, 93%  and/or quitting or reducing their substance use, as the inter-connections between these outcomes were evident. In one client’s words:n = 20 or roughly 16% of those interviewed). These were:Increased self-confidence/self-esteem;Reduced isolation and/or increased connection to peers;Increased self-compassion/self-determination.Three additional “most significant change” themes are important to mention, given that they emerged in the comments of quite a few clients  including learning more about parenting and having opportunities for positive peer connections for themselves and their child(ren). This lends further weight to the tenet that when working with vulnerable women, the child is “undeniably part of the equation” . At the For almost one-quarter of clients, improved housing was reported as a, if not the, most significant change in their lives. As four of the co-creating evidence study programs offered housing to at least some clients either on-site  and others achieved this through partnerships with local or provincial housing providers, clients were able to more readily access supported/social housing as a result of their association with their program. Safe and stable housing is fundamental to satisfying the safety concerns of child welfare authorities—i.e., enabling women to be able to go home with their infant after giving birth and/or to regain custody of older children—as well as to sustaining other positive life changes.Poor health or mental health were key issues at intake and were areas in which clients experienced positive change as a result of their involvement with the programs. For women, this “significant change” was characterized as an overall sense of wellness and social connections; a frequent theme was their experience of improved mental well-being, increased support, and self-confidence/self-esteem, reduced isolation, and increased self-compassion and self-determination. In describing the pathways that mothering women take toward quitting their substance use, Marcellus similarly found that restoring their sense of self—described as gaining and sustaining recovery, becoming more socially connected and less isolated, improving personal well-being, and regaining credibility in multiple domains—was a key trajectory for women . In thisFinally, it has also been noted in the literature that women respond differently to substance use services than do men, showing a preference for services and programs that engender an atmosphere of hope, acceptance, and support . EarlierDespite the strong congruence between this study’s findings and the existing literature, the study’s limitations should be noted. With regard to the on-site client-related data collection , we understand that the voluntary sampling approach could have resulted in biases, in that clients with more positive views about their program would have been disproportionately inclined to take part in the evaluation study. As well, without the denominator in terms of potential participation in the evaluation, we cannot assess bias nor the representativeness of the sample. Further, with a circumscribed number of days for each site visit and on-site data collection, clients had a narrow window of opportunity to take part. As such, we cannot know for certain that we achieved “saturation,” nor was the concept of saturation the means by which we determined the number of interviews to conduct at each site. Nonetheless, we have no reason to believe that clients who held fewer positive perspectives were disinclined to participate in the study nor were they prevented from doing so. The confidential, conversational approach to interviewing also facilitated participants sharing their diverse experiences and perspectives. Given that there will be a second round of on-site data collection with clients, there will be an opportunity to explore the issue of sampling bias and determine whether saturation was achieved.Women’s prenatal alcohol use and other substance use frequently occur within the context of inadequate housing, intimate partner violence, trauma, poverty, and social isolation. These burdens combined with systemic barriers affect their ability and willingness to engage with formal health care services. Often, women reveal the full extent of their substance use, including alcohol, only when they feel safe, accepted, not stigmatized, and when their program/service is meeting their practical needs.With its focus on clients’ perspectives, this paper makes a valuable contribution to the literature regarding multi-service programs aimed at vulnerable pregnant and parenting women who use alcohol and other substances. The article highlights the multiple, interconnected reasons why women seek help from these programs, most notably the twin desires to address their substance use and to regain and/or keep their baby/children in their care. Rounding this out are women’s desires for help with housing, prenatal/health care, and peer support, suggesting that pregnancy can be an important catalyst for making significant life changes.This study affirms how capably women can provide such guidance to service providers as to their service needs. It also affirms the value of a holistic approach that addresses both problematic substance use and the social determinants of health in accessible, women-centered, and integrated programming.To ensure that this population of vulnerable pregnant/parenting women receive such holistic services, funders too will need to consider how to integrate funding streams, to include health, social and cultural services, housing, income support, child welfare, and public safety resources to these multi-service programs.


This project characterizes spread of quality improvement (QI) projects initiated in the U.S. Department of Veterans Affairs (VA) Geriatric Scholars Program (GSP) workforce development program. This mixed methods study analyzes a recent cross-sectional survey of GSP participants and program-level data on participant characteristics and QI project topics. We surveyed 578 scholars who had completed all program requirements to that point, and still worked for VA; 207 (35%) responded. The majority of respondents who had been in the program for at least six months (70%) reported sustainment of their QI project beyond initial implementation and nearly a third (30.4%) reported any spread beyond their own care team. QI project topics spanned many domains and percent of projects reporting spread varied across domains from 0% to 67%. A workforce development capstone activity in which participants demonstrate substantive and methodological competency can foster bottom-up QI activities in a large, diverse health care system.


With the aim to enhance the senior nursing managers to be caring leaders so that they can nurture their team members to be holistic care providers, a one year program has been developed with emphasis on self-reflection and self-cultivation.It aims to evaluate the effectiveness of a one-year leadership enhancement program in an acute general hospital.Both quantitative and qualitative approaches were adopted. A pre and post questionnaire survey and the content analysis of self-reflective essays were conducted.The overall means of the servant leadership scale and the workplace wellness scale were significantly higher after the program. Both scales were also found to have a significantly medium level of positive correlation. Reflective essays showed positive feedbacks complementing the quantitative data that the program was well received and effective.A servant leadership approach may be one way for hospital management to enhance a caring environment and a more quality workforce. Hospital predecessors have already set up a good foundation in terms of structure, policy, educational activities and role models. However, compassionate care has to be cultivated by everyone in the hospital and passed from one generation to the next. The nursing administrative department believed that senior nursing managers are an important part of the staff who can uphold the caring heritage and influence their teammates. In return, junior staff will provide a high quality of care to clients and learn to be caring leaders in future. Furthermore, the nursing shortage is a common phenomenon in many advanced cities, Hong Kong is of no exception. To ensure a quality nursing workforce in a time of labor shortage, nursing managers in executing strong nursing leadership play an important role in supervising and supporting the frontline nurses [With the aim to enhance the senior nursing managers to be caring leaders so that they can nurture their team members to be holistic care providers, a one year program has been developed with an emphasis on self-reflection and self-cultivation. With the belief that lives influencing lives, the program expects participants to share, to learn from one another and build up mutual support in the nursing team. The program was started in April 2016 and ended in March 2017. The contents of the program consisted of one seminar per month for 5 months. Each seminar was a 1.5-hour talk during lunch break. Then, it followed with five sessions of small group sharing with 1.5 hours during lunch break or in the afternoon. The last part of the program was a one day retreat. The total hours spent on the program were 21. This paper reports the outcomes after the implementation of this leadership enhancement program.2A number of studies show that the nurse managers and her engagement with her staff is a key factor in nurse job satisfaction despite working in a stressful environment. Satisfaction usually comes from managerial care, support and respect -5. There1).The servant leadership model is adopted in this program to encourage participants to put subordinates first, to be humble and learn from one and other. On the other hand, it is also important to take care of oneself before taking care of others . A perso3Both quantitative and qualitative approaches were adopted in the assessment of the effectiveness of the program. A pre and post questionnaires were sent to participants of the program. After the completion of the program, participants were also asked to return a self-reflective essay for content analysis. Invitations were sent to all senior nursing managers of the hospital including Department Operation Managers (DOM), Nursing Consultants (NC), Senior Nursing Officers (SNO), Ward Managers (WM) and Advanced Practice Nurses(APN) of all units. Totally 42 senior nursing managers joined the program. All participants joined the program voluntarily. They are free to fill in the pre and post tests of the survey and submit with the anonymity of questionnaire which was only marked by self- assigned code.3.1A1) which composes of 7 categories: forming relationships with subordinates, empowering subordinates, helping subordinates grow and succeed, behaving ethically, having conceptual skills, putting subordinates first, and creating value for those outside of the organization [The questionnaire consists of two sets of scales. The first one is a general measure of servant leadership (Appendix nization . Each caA2) which composes of 4 domains: work satisfaction, organizational respect for the employee, employer care and intrusion of work into private life. This Workplace Well-being Questionnaire (WWQ) contains 31 items. The participants were asked to rate the items that best represented their current and most relevant work situation on a 5-point scale: 0, not at all; 1, slightly; 2, moderately; 3, very; and 4, extremely true. This questionnaire was found to have a high test-retest reliability, Pearson r=0.91 for the overall scale [The second set is a measure of well-being in the workplace .Out of 42, 26 participants have returned their pre and post-test questionnaires, the returned rate was 62%. Regarding the scoring of the servant leadership scale, participants got scoring from 4 out of 7 categories and the overall mean significantly higher after the program. Details can be seen in 4.2.3I really enjoy this program and appreciate the effort from the coordinators. In this program, I could realize the different aspects of myself. This program was full of touching, sharing and stories and gave me a chance in a tranquil environment to revisit the value, mission and my dream in nursing. The topics of this program were diversified and the expert speakers provided the substantial content to enlighten me. The program made me think my work, family and life in multi-dimensions. (Essay 1)4.2.4To me, the course is a bottle of spiritual nutrients throughout my year in 2016-17. Having worked in nursing for many years, there are times that I have lost direction, shifted/lost the meaning and value of nursing or even in life because of all the chaos. Nonetheless, all the sessions have energized my spirit, to refresh and keep going. Finally, I would like to thank the course coordinators for their dedication and effort for the future nursing leaders. (Essay 4)4.2.5Three themes emerged with more than half of them mentioned in their sharing: Reflecting and refreshing; gain more self-understanding and reviving. Some of their sharing are illustrated below.4.2.6I think I am lucky to be one of the members of the program that I could have opportunities and time to stop and think. In fact, I can do it while I am free, but usually, I will be distracted by other staff. Honestly, I seldom ‘stop and think’ in my day-by-day busy working life which drains all my energy at the end of the working day. I think it is good for me to have an ‘official’ time to think more about myself, my career and my future. (Essay 6)I was wrongly assumed that I have already mastered many techniques at my age getting to retired and thought that this was merely a day camp with nothing new and time could easily be passed. Unexpectedly, the first item “technique cards” already made me rethink that I turned out haven’t made good use of many techniques.In the afternoon session, Dr. Choi was invited to be a speaker and I gained a lot from his sharing. He made me think again how to maintain my holistic health. Every day is a busy day, it does not only make you feel tired physically but also spiritually. We really need to take care of our holistic health in order to take care of the people around us. (Essay 5)4.2.7Although I thought the tutorial group would not be as attractive as a lecture, however, it gave me a chance to explore myself. I came to understand more of my strengths and weaknesses, and the type of “leader” I belong to. It acts like a mirror to allow me clearly see how could I live my life and what could I contribute to nursing. After recovery from illness, each day is a bonus for me. I really did not want to waste my life. However, in the busy days, I am getting lost…. (Essay 7)The exercises in sharing sessions can enhance self-understanding and know others’ strengths. The group with similar seniority from a different background can create non-political resonance. By sharing with one and other, we can know others’ perspectives and find the way out. Greater exposure can cultivate support and networking with each other to be companions on the lonely road. (Essay 2)4.2.8PPEP program is a booster on my way. It refreshes my energy to continue. Besides, to sustain the seeding on me, I shall try my best to nourish those I meet. I believe little thing can make differences. Life influences live. (Essay 2)The fire in my heart being rekindled. Nowadays, I would not focus on how much was given to me by others, but how much I can do for others. In the past, I was being nurtured by my seniors. Today, I hope to be a blessing for others, nurture the juniors and help them to grow. Hoping that my hospital has more and more blessings in the future. (Essay 7)The focus of this day camp was not on teaching techniques, but have reflections on life and work. We reflected and discussed our works through the movie “The Five People You Meet in Heaven”. My conclusion is, I have to change my attitude, to regain my original intention in nursing, to rekindle my passion, and to love my work. (Essay 5)5The pre and post-tests showed that there was an overall improvement in servant leadership particularly in the areas of empowering subordinates, behaving ethically, having conceptual skills and creating values for those outside of the organization. There may be several possible reasons for this positive result. First, the nursing administration demonstrated the respect and care to senior managers in organizing this program with the aim to enhance their leadership knowledge and skill. This may exert a positive influence on them to act in the same way to their followers. Second, this program introduced the philosophy and practice of the servant leadership and encourage managers to act in the best interest of their followers. More leadership potentials are unleashed and participants may also influence one another. Third, during the whole year of implementation, a culture to serve and care is much more reinforced, which help participants in the program to put theory into practice.The pre and post tests also showed that there was an improvement in the workplace wellbeing in all areas and overall mean except in the area of “intrusion of work in private life”. It is understandable that participants will perceive more respect from the organization and employer care since the nursing administration has invited training experts in designing and facilitating the whole program for them. The program coordinator sat in the whole program for support. Regarding no improvement in the domain of “intrusion of work in private life”, some possible reasons may be: first, in time of shortage of nursing workforce, overtime is not uncommon for nursing management in nearly all acute hospitals in Hong Kong. Furthermore, the studied hospital serves a densely populated region with more than 500,000 population. It is sometimes difficult not to bring paperwork back to home or staying late to finish work at hand. Finally, maintaining a work/life balance takes time for improvement.The correlation test showing a medium level of the positive relation of servant leadership with workplace wellbeing provides a further support of the effectiveness of servant leadership which is also consistent with other studies overseas , 20, 21.With regard to the reflective essays, though not many participants submit theirs, the feedbacks compliment the quantitative data that the program is well organized and effective. It provides time and opportunities for senior nursing managers for reflection and refreshing. The serving hearts are revived. They are re-motivated to serve and pass the compassionate care to their followers.6Regarding the quantitative approach, it is only a pre and post test designs and the long-term effect of the servant leadership is not known. If assessment after six and 12 months can be taken, a better picture may be obtained. Furthermore, this study only provides one perspective from the senior managers, if views from their followers and patients can be considered, a more comprehensive picture can be seen. Relating to the qualitative approach, if focus group or individual interview is conducted, more in-depth data can be collected for content analysis.6.1st century, there will be a great demand for hospital services due to increasing the aging population in Hong Kong. A labor shortage with possible declining work satisfaction will be the challenges of hospital administrators. A servant leadership approach is shown to be one way for hospital management to enhance a caring environment and a more qualified workforce. This program based on a servant leadership model, on one hand, helps nurse managers to lead by follower-center than self-center and use of self-reflection and self-cultivation. On the other hand, it also reminds them that a leader is no more than a human who needs to take care of oneself while taking care of others. Since it is an initial project of the hospital for training of nurse managers, further research should be conducted to assess its effectiveness for training another batch of nurse managers on a more solid mixed research approach.Moving towards the 21A leadership enhancement program based on a servant leadership model with emphasis on self-reflection and self-cultivation was found to be effective in promoting nurse leaders well-being in one acute general hospital. This program is worth to be considered as an in-service leadership training program in other acute hospitals. However, further research should be conducted at the same time to assess its effectiveness to build up more evidence.