# Enhancing infant pain assessment and treatment: investigating barriers, facilitators, and implementation outcomes with the ImPaC Resource

## TL;DR

This study examines how to improve pain care for infants in NICUs using a web-based strategy called ImPaC, identifying factors that help or hinder its success.

## Contribution

The study introduces a tailored implementation strategy for infant pain care and identifies specific factors influencing its adoption in NICUs.

## Key findings

- Engaging key stakeholders and having champions were strongly associated with better implementation outcomes.
- Available resources and relative priority were identified as major barriers to implementation.
- Tailoring the strategy to local needs can improve the feasibility and fidelity of the ImPaC Resource.

## Abstract

The Implementation of Infant Pain Practice Change (ImPaC) Resource is a 7-step, multifaceted, web-based implementation strategy to improve pain assessment and treatment in Neonatal Intensive Care Units (NICUs). We explored facilitators and barriers to implementing ImPaC and their relationship to implementation outcomes.

A hybrid type 1 effectiveness-implementation study was conducted using a cluster randomized controlled trial (reported elsewhere) and a mixed-method exploratory study design. Level 2 and 3 Canadian NICUs with >15 beds were invited to participate and were randomized to intervention (INT, n=12) or usual care (UC, n=11) groups. INT NICUs recruited a change team who accessed ImPaC for 6 months; UC NICUs were waitlisted for 6 months and then offered ImPaC. Focus groups were conducted with all change teams following ImPaC completion. The Consolidated Framework for Implementation Research (CFIR) guided interview questions and analyses. Professionally transcribed interview data were coded and analysed using directed content analysis. Valence (+/-) and strength (–2, –1, 0, +1, +2) were assigned for each CFIR construct/subconstruct. Inductive codes were identified. Relationships between CFIR constructs/subconstructs and ImPaC implementation outcomes (feasibility and fidelity) were determined.

83 NICU change team members (median 4/site) participated in focus groups; 1,105 discrete codes relating to 31 CFIR constructs/subconstructs were identified. The most frequent facilitator constructs were Design Quality and Packaging, Compatibility, Available Resources, Champions, Implementation Climate, and Engaging Key Stakeholders. Complexity and Reflecting and Evaluating were salient in 21 transcripts, and Patient Needs and Resources was identified in 20 NICUs. Available Resources and Relative Priority were barriers. A positive association existed between the feasibility of implementing ImPaC and Engaging Key Stakeholders (0.46, p=0.041), Champions (0.82, p=0.001), Relative Priority (0.75, p=0.001) and Networks and Communication (0.60, p=0.023). There was a positive relationship between Engaging Key Stakeholders (0.42, p=0.048), Relative Priority (0.85, p=0.002), Patient Needs and Resources (0.46, p=0.049) and Fidelity.

Site-specific tailoring to enhance facilitators (e.g., champions, implementation climate) and mitigate local barriers (e.g., resources, relative priority) will provide a viable influence on optimizing implementation outcomes.

The online version contains supplementary material available at 10.1186/s43058-026-00856-8.