Addressing the How of Implementation: A Hermeneutic Exploration of Implementing Virtual Kidney Care in a Remote, Rural Health Region

ABSTRACT

Rationale

Implementing evidence‐informed healthcare services is typically approached as a structured, time‐limited project, focused largely on what to do. Less well understood is how implementation actually unfolds in practice: the ways in which those involved navigate change and generate solutions in diverse community settings. Without understanding how implementation happens in unique contexts, implementation failure may remain poorly understood.

Aim

The aim was to understand what it means for kidney care team providers, information technology staff, and patients to engage in implementing an evolving virtual kidney care service in a large, sparsely populated rural and remote region.

Method

We interviewed eight kidney care service providers, two information technology specialists, and 17 patients in northern British Columbia, Canada, for their experiences in implementing, delivering, and receiving virtual kidney care and how their practices changed with COVID‐19. Through an inductive, reflexive process of analysis and hermeneutic interpretation, we identified patterns in how virtual kidney care was implemented.

Results

The analysis showed six hermeneutic principles of implementation at work in the everyday practices of the kidney care and information technology teams: acknowledging central concerns, creating new common understandings, collectively acting, surfacing tensions, being responsive to context, and engaging in ongoing dialogue. Rather than discrete, technical, and time‐limited, we found implementation to be an ongoing, evolving, relational, generative, and iterative process that is inextricably connected to its context, and that never fully ends.

Conclusion

Attending to the how revealed dimensions of implementation practice that are seldom visible in conventional implementation research. A hermeneutic sensibility, marked by openness, humility, and dialogue, with a commitment to understanding, responsiveness, and relationship‐building, is key to implementation, especially in the ever‐changing contexts of rural and remote areas. The findings point to the value of a hermeneutic approach in implementing, sustaining, and researching innovations in dynamic healthcare systems and rural settings.

Abbreviations

BC

British Columbia

IT

Information Technology

NH

Northern Health Authority

UNBC

University of Northern British Columbia

1. Introduction

Considerable gaps remain in understanding what makes for successful implementation of a program or service and its continuation over time. Within implementation science, implementation is depicted as an intentional, structured, time‐limited effort to introduce evidence‐based knowledge into practice and is considered to be complete when outcomes of the implementation can be rigorously evaluated [1]. Both the practice and study of implementation are increasingly expected to be structured by theories, models, and frameworks [2], which often include implementation strategies and process components – about what to do. Studies of implementation rarely capture the realities of implementation in practice, which is “complex, non‐linear, and heavily context‐dependent” [3]. In many implementation studies, context is ignored or carefully delineated into facilitators or barriers to implementation, intended fidelity, or uptake, with little attention to how context can be understood in its interplay with implementation [4]. The how of implementing is seldom directly addressed.

With few exceptions [5, 6], studies of healthcare implementation experienced by those involved usually inform the what of implementation, the steps to be taken to ensure effective implementation. We seldom gain insights into the actual actions and ongoing processes that are interconnected with the often‐evolving actions and interactions of the organizational context in which interventions are being implemented. As a result, failures of implementation persist [3] and remain attributable to vague reasons, such as barriers, limiting what can be learned from the experience of implementing.

One key aspect of the wide gap between implementation research and practice [3] is that implementation in practice is not merely the creation, activation, and evaluation of a set plan, but is a process unfolding over time. Studies using patient partnerships, co‐production [7], integrated knowledge translation, participatory action research, and collaborative inquiry approaches [8, 9, 10] address the dynamic, interactional aspects of implementation. Nevertheless, not usually addressed are contextual realities or change processes that continue to develop over time in response to system need [11].

The often uneven progress of implementation is seldom explored. As a result, important and often overlooked realities of implementing programs or services remain out of view. Researchers rarely question assumptions underpinning conventional implementation approaches or those already at work in the context, and seldom illuminate the messiness of how implementation occurs over time. Through a hermeneutic approach, the “how” of implementing can be addressed and made visible.

1.1. A Hermeneutic Approach to Research and Implementation

Rooted in the philosophy of interpretation [12], hermeneutics is about understanding through interpretation. It holds that we are interpreting beings, whose ongoing actions and practices are interpretive acts as we seek to understand and be understood [13]. Hermeneutics holds that our everyday experiences are shaped by our cultural influences and social environments. Hermeneutics focuses on dialogue, temporality, and context. Language plays a crucial role, as word choices reflect understanding and may prompt different ways of acting. Conversation is a vital tool for unmasking assumptions, addressing priorities, and shaping practices by paying attention to other points of view. Gadamer's concept of “a fusing of horizons” [12] underscores the potential of coming to understandings through open dialogue that serves to broaden or change perspectives. A hermeneutic approach to research draws attention to the lived experience of people in complex, dynamic situations and reveals what may be taken for granted, overlooked, or invisible, and what may not be encompassed in theories or frameworks [14].

We conducted a hermeneutic‐informed scoping review of the intersection of hermeneutics and implementation [15] in which we identified how studies expressed features of hermeneutics (dialogue, context, temporality, processes of change, expanding understanding, and interpretation) while implementing evidence into practice. As a result of the analysis and interpretation, we articulated a hermeneutic approach to implementation in which six principles can be seen to be active (Table 1).

Table 1.

Hermeneutic principles of implementation.

Hermeneutic principle of implementation

1. Acknowledgement of the central concerns of power, communication and common actions which are active within an issue or problem 2. Promotion of new ways of seeing situations and creating new common understandings throughout the implementation process 3. Collective action that empowers and shows humility and respect 4. Actions that surface tensions and work with context in ways that illuminate possibilities for implementation 5. Processes that address context and the interplay of context with the program, service, or practice being implemented 6. Actions that foster engagement in dialogue and listening, action and reflection throughout the implementation journey.

From MacLeod et al. 2023 [15]

A hermeneutic approach to implementing emphasizes the importance of understanding the unique contexts, values, and perspectives of individuals and teams, while focusing on how they gain knowledge, deepen their own understandings, and act over time to implement programs, services, or practices [15]. It has the potential to support effective, responsive, relevant, and practical action [15, 16]. A hermeneutic approach not only considers time to be a resource in the context of implementing, but also, importantly, seeks to understand how implementation actions happen in the flow of time, drawing on the past while moving towards the future [15, 17].

Studies in the scoping review that took a hermeneutic approach to implementation emphasized understanding context, valuing diverse perspectives, integrating reflection, and creating conceptual knowledge and integrating that knowledge in practical ways. Those engaged in implementation gained deeper insights through examining their own experiences and the perspectives of others, as well as fostering a reflective process that extended personal and professional knowledge [18]. The studies showed how a hermeneutic approach goes beyond instrumentally applying theories or other knowledge to developing new, practice‐based actions in areas such as clinical reasoning through deeply understanding and contextualizing knowledge [19, 20]. Those engaged in hermeneutic implementation projects became differently attuned to their contexts and experiences [21], recognized nuances in patient behaviours [20], identified and articulated the overlooked objectification of patients [22], or fostered cultural humility and promoted cross‐cultural communication [23]. All found themselves able to see new possibilities for understanding and taking action.

As well as the scoping review [15], we undertook a hermeneutic study to understand and articulate what it means to engage in an unfolding implementation of an evolving virtual kidney care service. The kidney care service was provincially recognized for its successful implementation. At the outset of the study, we did not know whether or not virtual care was being implemented through a hermeneutic approach.

1.2. Implementing Services in a Rural and Remote Setting

The study was conducted in Northern British Columbia (BC), within the Northern Health Authority (NH), which serves ~300,000 people across 32 communities and 55 First Nations. The region covers the northern two‐thirds of the province, an area the size of France, and is sparsely populated, with only one city exceeding 75,000 residents. Healthcare leaders and point of care providers are faced with widely differing capacities, strengths, and limitations across communities [24].

The NH virtual kidney care service, delivered in partnership between the Provincial Health Services Authority and NH, was initiated in 2015 as a hybrid model combining in‐person and virtual care. Implementation was guided by an intuitive/experiential approach. The leaders of the service, which was underway when the study began and continued to develop, volunteered to engage in the study.

Virtual components included video appointments and telephone check‐ins for patients in pre‐dialysis stages or post‐kidney transplant. In‐person appointments occurred at the University Hospital of Northern BC (UHNBC) in Prince George, while virtual consultations connected patients from 32 remote facilities to the regional kidney care clinic interprofessional care team in Prince George. Clinical practice followed standardized provincial guidelines [25]. A typical virtual or in‐person appointment lasted about 2.5 h and included consultations with a nurse, dietitian, pharmacist, social worker (as needed), and nephrologist. In response to COVID‐19 (March 2020), in‐person visits were almost eliminated. Full‐team appointments shifted to telephone delivery.

1.3. Implementation of Virtual Kidney Care

Telehealth refers to activities used to deliver care at a distance, without direct physical contact with the patient [26]. The goal of virtual services in kidney care is to reduce spatial, geographic, and temporal distance between patients and care providers, improve access to care and health outcomes, and alleviate disproportionate travel and expense burdens on patients and families living in rural and remote communities [27]. Real‐time virtual consultations are increasingly common and often designed to mimic face‐to‐face kidney care appointments [28, 29].

Research on virtual kidney care implementation has focused primarily on the what of implementation: the feasibility, accessibility, or acceptability of services [30], benefits, opportunities, challenges, facilitators, and barriers [31, 32], implementation strategies [33], or outcomes [34]. There has been little or no attention to how implementing happens on the ground, how innovations evolve, or how care practices and patient experiences change in response to new care delivery models [35].

The purpose of this study is to understand what it means for patients and providers to engage in implementing a clinical service.

Objectives

• 1.To articulate how implementing a virtual care service in northern BC occurred and continued to evolve
• 2.To understand the experiences among patients and care providers of implementing a virtual kidney care service
• 3.To articulate the most salient features of implementing a clinical service from a hermeneutic perspective

2. Methods

2.1. Design

Our design was qualitative, exploratory, and inductive, underpinned by philosophical hermeneutics [12, 36]. By questioning assumptions and engaging in dialogue with participants and texts, we sought to uncover how implementation unfolded and raise new perspectives about implementation processes and practices.

The research team brought diverse positionalities across gender (women: authors 1, 3, 4, 7, 9; men: authors 2, 5, 6, 8, 10), disciplines (nursing, medicine, sociology, divinity), roles (researcher, clinician, patient), and philosophical perspectives (hermeneutic, constructivist, pragmatic, and realist). Most of the team lived in Northern BC and had experience in implementing and providing services in small rural and remote communities. All had experience in qualitative and quantitative research; six (authors 1, 3, 4, 5, 6, 7) had expertise in philosophical hermeneutics and three (authors 1, 9, 10) had expertise in implementation science.

The study received harmonized ethical approval from the University of Northern British Columbia and Northern Health (REB H20‐02263) and operational approval from Northern Health. The study was conducted in accordance with the Declaration of Helsinki (2024) and Canada's Tri‐Council Policy Statement: Ethical conduct for research involving humans (2023). All participants provided informed, written consent.

2.2. Participants

We recruited 17 patients (11 women, 6 men) and 10 care providers/information technology (IT) specialists (8 women, 2 men; nephrologist, nurses, dietitian, pharmacist, unit clerks, IT specialists). The clinical leader identified patients who had contributed to virtual kidney care planning and provided them with oral and written information about the study. Patients either contacted the research coordinator directly to participate in the study or consented for a care provider to give their contact information to the research coordinator. All kidney care providers were invited to participate and were sent an email by the research lead (author 1). The kidney care service professionals contacted the research coordinator directly and volunteered to participate. No participants withdrew over the course of the study. Each participant received a CAD $25 gift certificate for a coffee shop chain.

2.3. Data Collection

Between November 2020 and February 2021, two senior researchers (authors 1, 6) and a research trainee (author 4) conducted 27 individual participant interviews through Zoom or by telephone, depending on participant preference. Interviews lasted from 30 to 60 min. Questions for providers focused on implementing and delivering kidney care and how their practices changed with COVID‐19. Patients were asked about their initial experience with virtual care for kidney treatment and how they had experienced changes in the delivery over time (Interview guides are in the Appendix). The questions were open‐ended and invitational, with the conversational interview process designed to invite participants to reflect deeply, and relate as much detail about their experiences as possible [14]. Interviewers listened for and explored participants' experiences of changes, relationships, context, temporality, dialogue, expanding understanding, interpretation, and connecting differing perspectives. All interviews were audio‐recorded with permission, and transcribed by a professional confidential transcriptionist. Transcripts were de‐identified before analysis.

2.4. Analysis

We conducted the analysis through an inductive, reflexive process, working systematically and iteratively through the data, using MS Word. Six academically‐based team members with expertise in hermeneutics (authors 1, 3, 4, 5, 6, 7) undertook the initial analysis and interpretation through a process of reading all interview transcripts, creating substantive interpretive notes, and sharing and discussing the interpretations, returning to previous discussions and notes as new insights emerged [14].

We noted patterns in the data, keeping substantive quotes to remain attuned to the data's depth, complexity, and contextual nature. We explored how dialogue, context, temporality, interpretation, and expanding understanding showed up in the data. We compared interpretations and refined them with insights from relevant literature, keeping alert to patterns of connectedness and difference [14]. The full team discussed the interpretations and determined two main patterns in the data: the changing encounter and the process of implementing. The changing encounter was articulated in McCaffrey et al. [16].

This paper reports on the process of implementing. At the conclusion of the inductive analysis and interpretation of the implementation process, we used the principles articulated in Table 1 to frame the presentation of results. The team's different backgrounds, experiences, and epistemological stances contributed to our horizons, or already‐held contexts of tradition and language through which we share meanings [12, 13]. Through listening and extensive dialogue during videoconferencing and in‐person meetings and through writing, we kept our interpretations in question, revisited and extended our horizons, and came to common and deeper understandings [12, 13, 14]. For example, when discussing data on changing practices, a clinician spoke of expanding implementation of a protocol with clinicians in the region, a researcher with an administrative background focused on how the clerks ensured that the systems worked, and a researcher with expertise in hermeneutics and ethics reflected on how nurses and physicians learned how to deal with the loss of knowing the patient as an embodied, whole person. Through dialogue in person and through writing, we reached robust understandings about how the patient encounter changed through the virtual modalities [16] and how the processes of implementing occurred.

Prior to submission for publication, we provided participants with their quotes and interpretations for their review. There were no requests for revision or withdrawal.

3. Results: Practising Implementation Hermeneutically

Implementing the virtual service was not always easy or straightforward within the ongoing context of healthcare services, professional and patient expectations, and the available technology in rural communities. We considered the kidney care team and IT team's everyday practices, and present them below in relation to the six hermeneutic principles of implementation outlined in Table 1. As implementing was found to be an active process, the phrasing of the principles in the headings has been modified to express action.

3.1. Acknowledging Inherent Issues of Power, Communication, and Common Actions

The implementation process began with the Director of Information Technology (IT) and the Medical Director jointly conceptualizing virtual kidney care as a needed and different way of providing clinical care. The Director of IT said, “…we didn't change anything, we didn't cut short any visits … It was basically emulated on the model as if anybody was making a visit in the clinic.” Virtual care was designed to fit into the normal way of conducting the Kidney Care Clinic, not “just layering telehealth on top” as an add‐on service.

The Director of IT contrasted the approach with the experience of another telehealth application, where a virtual service was,

Completely delivered through a remote entity, [tertiary specialist hospital]. An external project manager was hired to implement it. They had a budget, and they had this [detailed] itinerary. So they weren't trying to learn. They were trying to implement and that's the standard way of doing it. So they came, and they designed it all down in a think box in Vancouver. And then came up to try to give it to us. A nice bow on top of it and here you go. It sounds nice but it's not sustainable.

In contrast to this “standard way of doing it” through an externally derived innovation with clear implementation steps and expectations, the virtual kidney care service was built through dialogue and joint action of the kidney care and IT teams. As the Director of IT said, “It was from scratch setting this up… It was that back and forth brainstorming and developing so that we could make it work … and we weren't cookie‐cutting it.”

Initially, a kidney care nurse in a remote community and a senior IT specialist in the regional hospital co‐led the implementation. They learned together by setting up and using the new video equipment in the remote hospital, exploring how the system and approach could work both clinically and technologically. The camera, video monitor, and audio set‐ups in the small hospitals or clinics were often in a room used for all other business and clinical videoconferencing. The nurse helped those at the regional centre understand how the system and patient encounters worked.

Communication and common actions were readily visible throughout the data, even though issues of power were not as evident. Agency was often shown in local actions where processes were changed to improve patient access, without requiring permission. Reports of decision‐making were mixed. While one staff member commented that the original decision to move to virtual care was not wholly supported by all staff members, another said, “the whole clinic decided” to make the change.

3.2. Promoting New Ways of Seeing Situations; Creating Common Understandings and Actions

The Director of IT placed IT staff where they could learn from clinicians and patients, to capture their values, intentions, and experiences. The care providers welcomed the IT team to sit with them throughout the day, learning how clinicians and patients worked together. The Director of IT observed that the approach of being in constant dialogue enabled a situation where “both [were] designing it and making sure it fit and was sustainable.” The clinicians, support staff (unit clerks), and the IT staff listened and learned from each other, to “speak the same language,” and learn about each other's world.

The co‐developed approach allowed the kidney care team to consistently initiate, implement, and evolve the innovation‐in‐context, even during rapid changes in the organizational and societal context of the COVID‐19 pandemic. This facilitative approach helped IT and kidney care team members reach common understandings, reflect on what worked well as well as imagine how processes could be changed to improve services.

3.3. Taking Collective Actions That Empower, Show Humility, and Respect

The whole team was engaged in making the changes. As a unit clerk said, “We were all part of the meetings.” The pharmacist noted, “Everybody was involved. We had patient satisfaction surveys to see where we could tweak things as we went along.” Patient participants did not elaborate when asked about the implementation, yet talked warmly about the changed encounters and the supports they received from the kidney care and IT teams. Team members spoke of being open to others' ways of working and learning from others. Through formal and informal meetings, they created a reflective space that helped empower team members to propose insights and possibilities for adjusting change processes.

Care providers, patients, and IT staff all spoke of dealing with unexpected events and how staff and patients adapted. Unexpected events included technological changes, unexpected positive changes, and unanticipated issues of patient need and emotion. Such events were not always welcomed or comfortable. Largely invisible but important work often shifted to others. Much of the work that shifted during the implementation fell to the unit clerks and administrative assistants.

Time‐consuming actions such as setting up appointments and sorting logistics for virtual care were often done in the background and were out of sight to the clinicians and patients. A successful virtual visit required many people to get the timing right; the patient could access the room and work the equipment at the remote sites, while the team could sequence their virtual sessions in a timely way. The IT specialists and regional kidney care unit clerks made sure things ran smoothly, including helping those in the distant sites to problem‐solve.

The administrative assistants at the remote sites added to their jobs informally, by opening the videoconferencing room and providing technical support or coaching. As one patient noted at a remote site:

They help you at the front, they will refer to somebody to come and help. … [When] something wasn't working right and they had to check it out, they were right there. And the last time, I wasn't sure if I was in the right place and time and I just phoned the [remote site] front desk and they found out … everything and made sure that I connected.

As many patients were older with chronic health concerns, including issues with vision and mobility, and were not familiar with technology, this last‐minute assistance often made for a smooth clinical encounter. These actions were hidden, usually taken for granted, and time consuming. The work was not part of the administrative assistants' jobs, but essential to effective clinical and technical functioning.

The unit clerks and the administrative assistants thoughtfully made unfamiliar technology comfortable for the patients. They “ironed out” the snags in the timing and booking of appointments through anticipation, communication, and creative problem‐solving, without explicit direction from anyone. For example, while scheduling an appointment, the clerk opened up possibilities for trusting relationships through conversation,

I mean you've met them because they came face to face and now they're virtual. So then you can say, “How are you doing?” … You talk about little things, … you're connecting more on a different level. There's a lot of trust and … it just sets them at ease when they know somebody on [the line].

Trust and relationship were important in helping patients to accept the new technology, as was the unit clerk's knowledge of the region and the contextual realities of each patient and community. The clerks and administrative assistants made important contributions to relational continuity, to make the distant seem familiar, and to help patients feel remembered or seen.

3.4. Surfacing Tensions and Setbacks, and Illuminating Possibilities for Implementation

In early March 2020, due to the COVID‐19 pandemic, in‐person appointments at all clinics were cancelled, and the regional kidney care team promptly resorted to connecting with patients virtually by telephone at the patients' homes rather than by video appointments in the local health centre or hospital. The quick transformation to telephone‐only care required a rapid change in workflow. Neither patients nor providers had input into the change; they were required to adapt as best as possible, as the Medical Director noted, “We didn't have time to think and pause, [and had] limited ability to refine the implementation process because of the crisis.” He contrasted it to the approach before the pandemic, when the team “would be pausing, thinking, taking feedback, implementing, pausing, looking at feedback, changing as we go along.”

The change to telephone care was both constraining and illuminating. It increased flexibility for both the patients and caregivers, who could take the phone calls from home. Patients could seek care in an anticipatory way by calling the clinic nurse with an early concern without wondering if it is “worth the trouble” of setting up an appointment. Unexpectedly, the length of calls became more variable, and the scheduling more challenging and time‐consuming for the clerks, as the first point of care for patients, who needed more communication and attention. As a clerk said,

So now phone appointments don't seem to take as long as an actual virtual appointment [and some] take longer I think there is a lot of positive flexibility out of it. The challenges [became] … making their appointment, even [the patient] coming to it or even answering their phone.

Tensions and setbacks were usually articulated as time‐consuming, often happening when adjusting to new processes or revising existing ones both within the kidney care program and in other parts of the healthcare system. As one of the nurses commented about making adjustments,

It's on top of your already busy workload. Sometimes you don't have the time or the patience or you're not in the best frame of mind to thoughtfully explore the options, [and when] all of a sudden the lab process has changed as well. They're swamped and overwhelmed, and things aren't being booked, and it takes repeated phone calls.

There was a sense among participants that they accepted the need for on‐the‐spot problem‐solving as it would be impossible to fully know all the moving bits within this complex healthcare system. Participants related how they absorbed the disruptions of new processes and made adjustments going forward, often realizing new possibilities for action as they problem‐solved together.

3.5. Addressing the Interplay of the Innovation, Context, and Implementation

The team adjusted implementation processes and the technology (the innovation) as they learned from patients and each other what mattered and how they might better address patient and service needs. Both team members and patients clearly understood the goals of responsive, respectful, high‐quality care, which they interpreted with their particular lens.

The care providers and support staff had much latitude to adjust care processes within provincial kidney care guidelines [25]. For example, when in‐person visits resumed following the COVID‐19 pandemic, the pharmacist changed practice in ways that kept the intention of the visit. They noted,

I've taken this on myself to try to minimize risk for the patient, risk for me, risk for everybody, and for nursing to have more time. I phone them the Friday before the week they come in, and I do my part over the phone. And I've found it very helpful for myself; then I don't feel like I need to take [the patient] away or [require them to have] another person that they have to be in contact with. … I've reviewed some bloodwork in between [the phone and in‐person visit] to make sure I didn't miss anything that they may have had done. Since COVID happened, I don't see those patients in person. I do my part a few days earlier.

Working together, the team shifted how work happened, experimenting in their own particular area of practice to find what could work best for patients.

The interplay of context and implementation was visible in the everyday adjustments to those closest to the practical realities of patients living in northern communities. As a clerk said,

When I'm scheduling, I always want to look at [their age], cause their clinics are morning clinics. I want to make sure that I'm not getting them up early. Or knowing where they live, how far do they have to travel, just within town. Those are all things I think of when I'm booking appointments for the patients, ‘cause a lot of them are elderly… whether they live in the northern communities or within town. You have to be thinking about how you schedule them.

Although issues in the broader context such as changes in lab services, the pandemic, and inclement weather were beyond their control, the team addressed the interplay of the kidney care service with the context in ways that reflected a willingness to listen and learn.

3.6. Fostering Engagement, Dialogue, Listening, Action and Reflection over Time

The process of implementing virtual kidney care unfolded over time and in response to changing circumstances. Reflecting the challenges of continual change, one kidney care team member resignedly named it “the never ending project.” Another commented more positively, “Now that it's in place you still find things that could be a lot easier, and [we need to figure out] how we're going to get them done.” The providers did not experience implementation as a time‐limited endeavour, but as an ongoing, never‐ending response and adaptation to practice shifts required by new technology, new patients and work groups, and external events such as the pandemic.

Although virtual care was originally identified as a project with a clear, consistent plan, implementation happened over time, influenced by system availability, system changes, and the context of the pandemic. System changes related to virtual technology, appointment‐making, and communications belied any sense of a stable, atemporal environment into which the virtual service was inserted and working within a set time frame. The implementation could not be said to be “done.” Ongoing iteration, flexibility, and change were required to be responsive to patient need while maintaining the evidence‐informed level of service.

The kidney care and IT teams' fundamental way of being was participatory and dialogical. That is, they sought to co‐create the service and changes to it. They attended to the timing and pacing of change as well as to a continued focus on patient experience and good practice. This dialogical way of being assisted those who were implementing care – both patients and kidney care and IT teams – to develop greater understanding. It buffered setbacks in the implementation and facilitated rapid changeover of care during the COVID‐19 pandemic. What made the ongoing implementation over time reasonably smooth for patients and care providers were relationships, trust, continuing dialogue, and expanding understanding that facilitated flexible, responsive action.

4. Discussion

This study was designed to provide an understanding what it means to engage in implementing a virtual service and to surface the processes and actions that contribute to this work. The intention was to articulate how the virtual service occurred and continued to evolve, to understand patients' and providers' experiences of implementing the service, and drawing on the hermeneutic research approach, to articulate salient features in the process of implementation. The study approach led us to focusing on the how of implementation.

When we looked at how virtual kidney care was implemented in Northern BC, we found that the approach aligned with a hermeneutic way of being and doing. That is, our findings show that implementing the service was an active, generative process where those implementing learned through their experiences and took actions that were not merely applying or tailoring knowledge or a program. Those implementing the innovation created reflective spaces that enabled dialogue and learning, along with new possibilities for action [37]. We found implementation to be inextricably interconnected with the ever‐changing context of the healthcare environment and with the distinct needs and resources of the patients, communities, and healthcare providers.

The implementation of virtual kidney care (video and telephone) in a sparsely populated northern area, could be characterized per the Nonadoption, Abandonment, Scale‐up, Spread, and Sustainability (NASSS) framework as complex, inherently dynamic, and emergent [38, 39]. Chronic kidney disease, a complex condition, required constant measurement and monitoring on the part of patients and care providers. Patients' abilities to manage the condition were influenced by socioeconomic conditions of housing, income, or the rural community in which they lived. The video‐conferencing technology was complex, with sometimes unreliable internet connectivity, and with the need to have assistance to use the video link in a hospital conference room. Telephone technology was simpler but it further disrupted the structure of the clinical encounter [16] and necessitated considerably more, often unseen, work on the part of the clerks to ensure clear and consistent communication with patients, clinicians, and other departments.

The virtual care implementation processes included Greenhalgh et al.'s [39] NASSS recommendations for practice in real world implementation of video consultations: allow plenty of time for discussion when introducing the innovation; work in collaboration with information technology department and technical support; understand patients' lives and how technology relates to the management of their condition; and support flexible use, fitting the service around the needs of the patient. At the same time, the processes of implementing virtual kidney care went beyond implementing a discrete project to become an ever‐evolving hermeneutic process of responsive change.

Implementation entails a reconfiguration of an already existing mesh of practices and relationships between people, places, things, and ideas [36]. Virtual kidney care was integrated into the ongoing flow of care in which patients, care providers, unit clerks, and the IT staff already had multiple and many‐levelled relationships. Although the changes were initiated by the Medical Director and Director of IT, they created a shared vision about implementing virtual care and how it would improve access and quality of care through dialogue with providers and patients. Care providers interpreted the vision into their own roles and responsibilities through reflection on their practices and in dialogue with others. They shifted their practices, innovating to find ways that worked better for patients. The process was an interplay between the planned and organic aspects of implementation, always in relation to contextual realities. This interplay is often invisible in implementation literature [3, 40].

Unexpected findings were how few experiences were related by participants about the process of implementing virtual care and the limited descriptions of setbacks in the process. The care providers and patients focused almost exclusively on their experiences of the changes in accessing care or in the changing character of clinical encounters, which were fully discussed in McCaffrey et al. [16]. As well, there was little mention of difficulties with the implementation itself. Instead, the references were to “ironing out” bumps or glitches. Those references were usually made by the clerks or IT specialists. The relative lack of focused data on the process of implementing itself speaks to how those involved consider implementing change to be part of their everyday practice, with problems to be worked through or solved, rather than the barriers and facilitators seen in much of the implementation literature [2]. It also suggests that, even though they are involved in determining changes, clinicians and patients within a changing service may not focus on the implementation itself but only on their direct area of practice or concern.

During implementation initiatives, there is often considerable thought put into clinicians' workload, but rarely acknowledged are the burdens that are shifted onto the assistants and clerks, who are often the face of the change. The largely invisible adjustments in the clerks' work and workflow meant they were problem‐solving about what was being implemented (virtual care) and about the implementation process itself. They figured out individually and together how to fix the glitches and smooth the implementation process. They created new ways of making things work. Administrative staff is often overlooked or under‐reported in implementation studies, yet they fill important gaps and address unforeseen challenges, especially when they feel empowered and can assume the responsibility to act. To overlook this invisible, background work can miss important, affective components of change.

The active interplay of those undertaking the change with the context of change was evident in the implementation of virtual kidney care. Those implementing the change shared a deep understanding about what it meant to live, work, and implement change in a large, northern region and in widely varying small communities. This shared understanding contributed to respectful, functional problem‐solving by the kidney care and IT teams. They engaged in a continuing process of responding to contextual realities in revising or adapting aspects of the service, which in turn, influenced the context of service in the small communities. Building the system and implementation processes in dialogue with those who were to use it and understanding realities of the rural context stood in contrast with the experience of those in many rural, sparsely populated areas, who are merely the recipients of centrally designed and rolled‐out virtual care initiatives [31]. The approach also stands in contrast to usual research on implementation, which often focuses on determinants [2] and the importance of fidelity to the intervention and the implementation process [41], although the importance of responsiveness to contextual realities is increasingly recognized [3, 40].

The kidney care team demonstrated how being flexible and shifting their horizons enabled them to implement services differently. We found them to be increasingly adept in implementing within the ever‐changing contexts of practice. The team's understanding of ways to improve practice expanded as they effected smooth transitions for patients and patient care.

We identified that a hermeneutic sensibility is the foremost characteristic of a hermeneutic approach to implementing. This sensibility exemplifies the movement of understanding “from the parts to the whole and from the whole back to the parts” [42]. Implementers look back and see how things have matured or adapted, while keeping understandings of current practices and the current context open to change, and moving forward on the basis of that broader understanding. It takes humility and an openness to hear and see possibilities inherent in differing perspectives, to reflect on taken‐for‐granted ways of understanding, and to see sometimes innovative ways to problem‐solve. This sensibility and stance create the preconditions to implementing and serves to empower those who are doing the implementing.

A hermeneutic approach to implementing, creates conditions that enable people to think the intervention is worthwhile adopting, much like in integrated knowledge translation [10]. It also holds similarities to community‐based participatory research in its democratic approach to the co‐creation of knowledge [8].

5. Strengths and Limitations

The research began with an intent to study the “how” of implementing, gathered from the experiences of those involved in an implementation which was considered to be going well. The hermeneutic research approach offered insight into the human face of implementing—to the experiences, expectations, the interdisciplinary teamwork, and co‐creating involved. It provided a view of the taken for granted, invisible work of those engaged in implementing change and how ongoing change can happen when those involved feel empowered to make change and own the implementation and the service. While observing care and implementation would have added to the study, we were unable to undertake observations due to health authority policies restricting research access due to the COVID‐19 pandemic and its immediate aftermath.

This hermeneutic study offers only one of many possible interpretations. The kidney care team, IT staff, and patients with longstanding associations with the kidney care service provided insights from program establishment, through more recent adaptations and “pivoting” due to the pandemic. The implementation process may have been harder to study and reveal different issues if the interprofessional team was less stable, or if communication and trust among patients and team members were lower. The experience, diversity, and interdisciplinarity of the research team members, including those involved in the implementation, contributed to a robust interpretation. Although we report the implementation of only one service in one rural and remote geographical area, the implementation processes and practices may resonate with those in other settings.

6. Conclusion

This study explored the experiences of care providers, including IT staff, and patients in implementing a virtual kidney care service in a remote, rural health system. The analysis shows that they were implicitly taking a hermeneutic approach to implementing. Their actions embodied hermeneutic implementation principles. Rather than a discrete or technical event, we found implementation to be a living, ongoing, evolving, and iterative process that never fully ends and persists over time. Changes were experienced in the innovation (virtual care) as well as in the implementation in response to an ever‐changing context. Those involved in the implementation, many of whom may not identify as implementers, consistently showed a hermeneutic sensibility, marked by openness, humility, dialogue, and a commitment to understanding.

The findings raise the possibility of differently conceptualizing the introduction and continuance of evidence‐informed services in complex healthcare settings and the value of responsive implementation processes and practices. Such processes and practices require the cultivation of ways of working that are respectful, responsive, dialogical, and relational, making space for concerns to be heard and valued. A key component is for those leading change to be comfortable with surfacing tensions and to really enable and give permission to those at the point of care to reimagine, problem‐solve, adapt, and generate processes to fit their various unique contexts. Without attention to the ongoing practices of implementing, gaps between the actual and the ideal cannot be closed, and those who actually engage in implementing will not be accorded the value they deserve. More studies of the implementation process using a hermeneutic approach are needed along with closer attention on how to incorporate a hermeneutic approach into implementation practice and science.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting File

Data Availability Statement

The data that support the findings of this study are not available due to ethical restrictions.