Table 1 CFIR domains, definitions, and occurrences in vignettes

Intervention characteristics

Intervention evidence strength and quality

Stakeholders’ perceptions of the quality and validity of evidence supporting the belief that the intervention will have desired outcomes

2/5 (40%)

3/9 (33.3%)

4 (2.3%)

“[the device allows delivery of] evidence-based practice regarding intensity of treatment.”

"One session would also not allow for achieving recommended frequency and duration to obtain the known benefits with use of the device"

Cost

Costs of the intervention and costs associated with implementing the intervention including investment, supply, and opportunity costs

1/5 (20%)

1/9 (11.1%)

2 (1.1%)

[none coded]

“I would have liked to use the device … but the device was … locked in a manager's office because it is expensive” (clinician stage of change)

Complexity

Perceived difficulty of the intervention, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement

5/5 (100%)

9/9 (100%)

16 (9.2%)

"I typically use devices or technology when it is easy to set up, requires less steps, time or burden of down time for my patients or burden of time outside of my clinical treatment and day to day tasks"

"Using … 1-h of physical therapy and taking at least 20 min … to set up 4–6 electrodes on each leg before testing and trialing for one 30 min training session is not ideal and not supportive of her … goals and time frame for her … stay” (relative advantage)

Adaptability

The degree to which an intervention can be adapted, tailored, refined, or reinvented to meet local needs

3/5 (60%)

4/9 (44.4%)

7 (4.0%)

“I can modify the speed …, body weight support, … [and] aspects of the set up … for those requiring a significant amount of assistance…” (design quality and packaging)

"Technology does not fit well in a small galley kitchen or in a tight spaced bathroom where my patient needed to practice"

Design quality and packaging

Perceived excellence in how the intervention is bundled, presented, and assembled

2/5 (40%)

2/9 (22.2%)

6 (3.4%)

“…it is easy to operate with its portable remote to allow me to change parameters in real time and not have to stop if I am changing speed or inclines. It has built in safety/back up options if the portable remote did not work, but also for emergency stops, which also are adjustable …”

“In design, … It is not user friendly. As clinicians, we believe in being objective when we record treatment. Due to no easy, clear, objective ability to measure weight bearing … we cannot objectively document how much weight we are using ….”

Relative advantage

Stakeholders’ perception of the advantage of implementing the intervention versus an alternative solution

5/5 (100%)

9/9 (100%)

32 (18.4%)

"…and if not for technology, [patients] would not be able to otherwise get up and perform this specific treatment."

"It is easier to setup a treatment using task-specific training with functional, everyday objects than try to make an unfamiliar device work." (complexity)

Outer setting

Clinician knowledge and beliefs about the intervention

Clinician's attitudes toward and value placed on the intervention as well as familiarity with facts, truths, and principles related to the intervention

5/5 (100%)

7/9 (77.8%)

18 (10.3%)

“It’s always easier to try new/unfamiliar interventions with patients who you have built a rapport with over time, and who you know would benefit from trying something new” (patient needs/resources)

"…we were hesitant to use it during a normal treatment time with patients since the device involved games when most of our patient's goals revolved around function (dressing, handwriting, etc.)."

Clinician stage of change—readiness

Characterization of the phase a clinician is in, as he or she progresses toward skilled, enthusiastic, and sustained use of the intervention

4/5 (80%)

5/9 (55.6%)

10 (5.7%)

"I was lucky enough to learn how to set up a patient for [the device] while I was a student…" (clinician knowledge and beliefs)

"The device lived on our floor for a while, a daily reminder of the guilt of never finding time to improve familiarity."

Other personal attributes of the clinician

A broad construct to include other personal traits such as tolerance of ambiguity, intellectual ability, motivation, values, competence, capacity, and learning style

4/5 (80%)

4/9 (44.4%)

4 (2.3%)

“After …residency early in my career, … I would consider myself an early adopter and enthusiast to learn new approaches for best patient outcomes…” (clinician knowledge and beliefs)

Despite being involved with technology in all roles, I would describe myself as a skeptic when it comes to consistent use of technology to treat the arm post neurologic injury

Patient knowledge and beliefs about the intervention

Patient’s attitudes toward and value placed on the intervention as well as familiarity with facts, truths, and principles related to the intervention

2/5 (40%)

3/9 (33.3%)

4 (2.3%)

“He ended up loving this intervention, because to him it was the closest he was able to get to lifting weights (something that was really important to him prior to his injury.” (relative advantage)

“I also find that when meeting a patient for the first time, doing something that they can understand will help them get back home is pretty helpful in gaining rapport”

Other personal attributes of the patient

A broad construct to include other personal traits such as tolerance of ambiguity, intellectual ability, motivation, values, competence, capacity, and learning style

5/5 (100%)

9/9 (100%)

27 (15.5%)

“Below is an example of a patient who checks all the boxes as being a “good candidate” for technology use- young, motivated, and willing to try anything.”

“However, I did not have many patients who would be appropriate for this equipment because they have cognitive deficits that limit attention, initiation, or comprehension of such games. Or they had extremely limited movement on their affected side.”

Inner setting (organization)

Patient needs and resources

The extent to which patient needs, as well as barriers and facilitators to meet those needs, are accurately known and prioritized by the organization

4/5 (80%)

6/9 (66.7%)

14 (8.0%)

"When it was time for him to leave, I provided him with information to get a cycle for home through the vendor that we had worked with, as she mentioned that she may be able to get him a cycle for a discounted rate since he was in the military."

"Finally, the patient’s wife is present and is very anxious, providing too many cues to the patient, overwhelming him and expressing disappointment with his performance."

External policy

A broad construct that includes external strategies to spread interventions, including policy and regulations (governmental or other central entity), external mandates, recommendations and guidelines, pay-for-performance, collaboratives, and public or benchmark reporting

3/5 (60%)

3/9 (33.3%)

5 (2.9%)

[none coded]

"…how do I balance what is required vs what is ideal (required insurance tasks, progress updates, outcome measures, what has the patient already done for the day, what is recommended best available evidence for the interventions that address their goals)." (relative advantage, intervention evidence, patient attributes)

Readiness to implement

Tangible and immediate indicators of organizational commitment to its decision to implement an intervention

4/5 (80%)

5/9 (55.6%)

12 (6.9%)

"[the vendor] was able to come to a co-treatment with the patient and I to help me with optimal setup."

"It had been a while since the 2-h training session that I went to …”

Overall implementation climate

The absorptive capacity for change, shared receptivity of involved individuals to an intervention, and the extent to which use of that intervention will be rewarded, supported, and expected within their organization

5/5 (100%)

5/9 (55.6%)

6 (3.4%)

“…is integrated as part of the new hiring system …. In my experience, learning to correctly use the machine has not been any issues after initial training/mentoring.” (readiness to implement)

“My colleague and I both lacked confidence and did not want to use normal therapy time to test out the device, but we decided to treat patient pro bono after clinical hours to setup and run through with the device to improve familiarity.” (external policy, clinician attributes, clinician stage of change)

Culture

Norms, values, and basic assumptions of a given organization

2/5 (40%)

2/9 (22.2%)

3 (1.7%)

“… appeal for “sexy” technology …”

"As an OT, we are taught 'function, function, function!', and this sentiment is reinforced by our professional organizations, and therapy leaders, that patient goals, daily interventions and treatment plans should address improved function."

Process of implementation

Executing

Carrying out or accomplishing the implementation according to plan

2/5 (40%)

2/9 (22.2%)

4 (2.3%)

"…we were assured that although the initial use would be confusing, consecutive uses become efficient."

"My confederate therapist and I could not coordinate another time to practice on the new device…"