Evidence-based practices (EBPs) can help reduce suffering and prevent premature death in those experiencing mental health conditions (1, 2). Yet, EBPs are underutilized among mental health clinicians and organizations (3, 4). Many individuals seeking mental health care do not receive empirically supported treatments (4) and there is a substantial gap between establishing empirical support and integrating an EBP into routine care (5, 6). Implementation science research aims to bridge this gap by investigating factors that promote and impede uptake of best practices while also developing and testing strategies to promote successful implementation (4). Implementation strategies are techniques or methods used to enhance the uptake, implementation, and sustainment of a clinical program or practice (7). While the field has focused on developing and testing strategies, mechanisms explaining how strategies operate need to be more thoroughly explored (8). Causal mechanisms explain the processes through which implementation strategies generate a desired effect or outcome and will allow researchers to better select implementation strategies based on their project goals (9, 10).

In the current paper, we examine causal pathways through which one such implementation strategy, the identification and preparation of clinical champions address and reduce provider-level barriers to uptake of EBPs. The “identifying and preparing clinical champions” strategy was selected due to its described impact on provider behavior change across implementation efforts (11). While this strategy is regularly utilized in various implementation efforts, less is known about the underlying mechanisms that may be contributing to its success. To inform the development of the proposed causal pathway mechanisms, the current paper provides a theoretically informed review of the current clinical champion literature to outline relevant attributes and describe common responsibilities and processes champions engage in.

Clinical champions are individuals who are dedicated to supporting, advocating for, and spearheading an implementation initiative, and who overcome resistance that may occur at the organizational level (12). They have an intrinsic interest to implement change and use their position to motivate others (13–15). Previous research has referenced clinical champions of a specific topic (e.g., hand-washing champions), discipline (e.g., nurse champion), or broadly within an organization or implementation effort (e.g., executive champion) (15).

Research involving clinical champions have begun to identify attributes that may impact an implementation effort (14, 16, 17). Clinical champions have been described as having strong communication and mentorship skills. Strong communication and mentorship skills involves processes including collaborating with others, advocating for change, ability to negotiate as well as educate and facilitate learning (15, 17). Strong communication and mentorship skills can facilitate buy-in by conveying their conviction and positive perceptions about the initiative to their peers (14, 17, 18). Champions can also effectively tailor messages to different audiences to maximize engagement and buy-in (15, 16, 18).

Previous research has also emphasized clinical champion's EBP knowledge and competency (14, 17, 19). Clinical champions often emerge due to their knowledge and previous experience which, in part, is how clinical champions promote EBP adoption within their clinical environment (13, 17). Additionally, as clinical champions serve as a resource for providers to develop EBP competency, effective champions must be knowledgeable, experienced, and have strong self-efficacy to effectively educate others (15, 19). Through their knowledge and expertise, clinical champions may also engage in skill-sharing, and promote benefits of integrating the EBP into clinical practice (13, 14, 17).

Clinical champions have also been described as being deeply embedded in their clinical setting. Embeddedness in the clinical setting means that a clinical champion has frequent face-to-face to contact with their peers as well as leadership and are regularly present on the frontlines (i.e., the point of change) (16, 20). This embeddedness results in a robust understanding of their setting's culture and workflow (16, 20). This embeddedness may allow the clinical champion to model integration of an EBP into their daily workflow as well as providing education and support to peers (16, 17). A clinical champion's presence in the clinical setting can have substantial impact on implementation; results from Rycroft-Malone et al. (18) found clinical champions' embeddedness allowed for a more grass-roots approach to implementation, which yielded better EBP uptake. This embeddedness also relates to clinical champions' institutional savvy (16), which allows them to effectively navigate the complex social hierarchies and culture that exists within their setting/organization. This allows clinical champions to identify points of potential resistance and leverage their relationships/influence to overcome resistance (16). Not only are clinical champions dedicated to their clinical practice (i.e., frequently on the frontlines), but they are also dedicated to their role and readily embrace change (15, 17, 19). This dedication to both the innovation and overall implementation effort may provide clinical champions with the drive needed to overcome resistance in their clinical setting, which may be key to their impact on both the implementation effort and provider behavior change (16, 17, 19).

Arguably the most impactful attribute of clinical champions is their standing as informal leaders in their clinical organizations (16, 19, 20). Informal leaders are regarded as highly influential individuals who do not hold positional authority but are highly respected due to their expertise, trust, and relationship-building capabilities (21–23). The power of informal leaders is defined as “one's ability to initiate action and ensure the desired outcomes are produced” (21). Informal leaders take time to emerge, as a provider needs to develop both the technical expertise and trust from others before being deemed influential (22). Clinical champions may be perceived as implementation experts by their peers and, due to being highly respected, are then able to actively engage them in implementation efforts (16, 19, 20). Although clinical champions may hold formal leadership positions (17), effective clinical champions are typically informal leaders (16, 17). The power being referenced throughout this paper is in reference to this “subtle” power informal leaders possess. Clinical champions' influence, power, and relationship-building capabilities have been considered crucial to implementation success (14, 16, 19). Additionally, clinical champions have been described as highly respected and valued individuals within their clinical organization who routinely establish meaningful relationships with their peers (14, 16, 17). It is through these meaningful relationships that clinical champions can effectively engage their peers in implementation efforts. Thus, the current paper defines informal leadership/influence as the following: an individual who is highly respected by their peers who establish strong and meaningful relationships with them and are viewed as a credible and reliable source of information and skill-sharing (14, 16, 19, 24, 25). It is important to note that clinical champions may overlap substantially with another group of influential individuals within healthcare organizations, local opinion leaders. Local opinion leaders are individuals who are respected informational sources who have influence over others' decisions and behaviors (24, 25). Both clinical champions and local opinion leaders are viewed a fellow peers who have an in-depth understanding to a provider's day-to-day experience while also being viewed as credible and reliable source of information (24, 25). Clinical champions also overlap with early adopters, individuals that readily adopt new ideas, are typically solution-oriented, and embrace innovation (26, 27). Yet, there are also areas where clinical champions may diverge from these groups. Clinical champions are unique to local opinion leaders, as champions act through charismatic leadership, as opposed to organizational norms and structure (24). Instead, clinical champions may take an active role toward shifting organizational climate to be more amenable to change (16). Additionally, clinical champions are unique to early adopters, as early adopters do not necessarily take the responsibility for promoting and spearheading change initiatives in their settings (28).

Clinical champions may be particularly relevant to an implementation effort due to their potential to influence the behavior of other frontline providers within their clinical setting. Frontline providers are essential to an EBP implementation effort because they have autonomy to make clinical decisions and can also utilize their power and influence to persuade others to adopt new practices (29). Each provider has their own unique set of values, interests, and ways of enacting the organizational culture (29), which may facilitate or impede their use of EBPs. The Consolidated Framework for Implementation Research [CFIR, (29)] model has identified provider-level determinants that impact an implementation initiative, including knowledge and attitudes about the implementation initiative (i.e., a specific intervention), self-efficacy (e.g., belief in one's own ability to carry out implementation goals), individual stage of change (e.g., progressing toward becoming a skilled and enthusiastic implementer), and identification with their organization.

Provider-level barriers have been identified across multiple studies and are generally defined as attitudinal or behavioral and involve cognitive or psychological processes that impede or prevent a target behavior from occurring (4). Commonly cited examples include knowledge, attitudes, and self-efficacy (3, 10). Barriers surrounding EBP knowledge, competency, or utility in a particular treatment context can impact providers' intentions to enact an EBP and/or their ability to deploy or sustain the EBP (4). Such barriers can persist and limit a provider's ability to deploy or sustain an EBP, even when they intend to do so (4, 30).

In addition to provider-level barriers, the CFIR model describes implementation determinants at other levels including the inner and outer setting (29). The outer setting refers to how external policy, economic, or social context impact implementation (29). In contrast, the inner setting refers to the setting-specific culture, norms, and general characteristics (i.e., geographic location, size) (29). Together, barriers that exist at different levels of the implementation setting may interact and in turn impact the implementation effort's outcome and success (29, 31). For example, results from Mosson et al. (32) found that managers in smaller organizations or those in rural areas had difficulty with implementation due to barriers that impacted them at the individual level, such as lack of training or preparedness. This occurred, in part, due to the organization's geographical location, causing training opportunities to be infrequent (32).

While it is important to acknowledge barriers at other levels (e.g. organizational, cultural), provider-level barriers may be important to target due to their amenability to change (33). Targeting an individual's beliefs, attitudes, or behaviors may be more feasible than addressing barriers at the system level. Previous research suggests that when EBP attitudes and beliefs are targeted via social persuasion tactics, EBP utilization and fidelity increased (33). Previous research has also emphasized a key factor to successful EBP implementation is most successful when line-level clinicians and organizational members are willing and ready to change (34). Thus, focusing on individual-level attitudes, beliefs, behaviors, or practices may allow for improved design, implementation, and generalizability of strategies to explicitly target such barriers (35, 36).

To reduce implementation barriers and promote uptake of EBPs in healthcare and other settings, implementation scientists have developed and tested implementation strategies (5, 10). Implementation strategies can target different populations including patients, clinical providers, stakeholders, and policymakers, as well as different phases (e.g., preparation, delivery, sustainment) and levels (e.g., individual, inner setting, outer setting) of the implementation effort (10). Given the range of implementation strategies that were being used and reported in the literature, Powell and colleagues (12) compiled a taxonomy of 73 common and discrete implementation strategies, the Expert Recommendations for Implementing Change (ERIC). The ERIC taxonomy was created using an expert panel and aimed to unify and standardize how implementation strategies are referenced and defined in the literature. Although the ERIC taxonomy has effectively allowed for standardized and well-defined implementation strategies, our understanding of how such strategies operate in real-world implementation efforts is limited (9, 10). Per the ERIC taxonomy (12), the implementation strategy “identify and prepare champions” is defined as, “preparing individuals who are dedicated to supporting, marketing, and driving through an implementation, overcoming indifferences or resistance that the intervention may provoke within an organization.” This strategy is a multi-faceted approach that prioritizes fostering stakeholder relationships, providing mentorship to line-level providers, and overseeing the implementation process (i.e., creating implementation plans, addressing barriers, engaging stakeholders) (17, 37, 38).

An area of the implementation strategy literature that needs to be more thoroughly developed is causal pathway mechanisms (9, 10). Causal pathway mechanisms outline the processes through which the implementation strategy of interest operate to impact one or more implementation outcomes (8). By better understanding how strategies operate to yield the desired outcome, researchers will be able to better select and modify implementation strategies to enhance both clinical and implementation outcomes (9, 10). Understanding processes of implementation strategies will help explain why a certain strategy is effective or ineffective and in what contexts they operate best (8). Most importantly, understanding processes of implementation strategies will allow for better strategy selection which in turn will better address barriers in the specific implementation context (8). Per Lewis et al. (8), if there is no intentionality behind strategy selection, a suboptimal or less potent strategy may be selected and applied to implementation efforts.

Existing frameworks, such as the Behavior Change Wheel (39), have been developed to examine how behavior change is most likely to occur given intervention components/functions and under certain policy conditions. However, linkages between certain implementation strategies and specific behavioral changes have not been as well explicated. Better understanding mechanisms will require implementation scientists to move beyond simply describing whether a strategy was effective toward developing testable theories that explain relationships between implementation strategies and outcomes as well as allow for outcome prediction (9, 10).

The current paper proposes two causal pathway models for one specific implementation strategy: identifying and preparing clinical champions (5). This implementation strategy was intentionally selected due to its potential for addressing provider-level barriers. When implementation researchers and practitioners were asked to rank the implementation strategies that would best address each of the CFIR barrier domains, identifying and preparing clinical champions was the most consistently rated strategy across all provider-level barriers (11). This implementation strategy leverages the influence and respect clinical champions hold within their clinical setting and the interpersonal relationships they form with other providers, which are particularly salient in the context of provider behavior change (40). By building and engaging in interpersonal relationships within their organizational setting, clinical champions can effectively mitigate provider-level barriers that impact a provider's intention and motivation as well as their ability to deploy an EBP.

While previous literature emphasizes clinical champions' power and influence as a crucial factor in this strategy's effectiveness (14, 16, 17), exactly how clinical champions change provider behavior has yet to be empirically examined. A conceptual model outlined by Shea (19) posits that a clinical champion's commitment to an implementation effort, as well as their experience, self-efficacy, and performance, promote peer engagement with a clinical champion, which directly influences a clinical champion's impact. A key component of this model is the need for clinical champions to facilitate buy-in from their peers (19). Clinical champions can promote buy-in by being knowledgeable, trustworthy, and reputable within their organization (16, 19). Clinical champions can also influence their peers through various forms of power, including expert power (i.e., ability to influence behavior due to skills, knowledge, and abilities), referent power (i.e., impact individual behavior through being well-liked and admired), and informational power (i.e., promote behavior change via exchange of knowledge) (41, 42). Expert and referent power are considered power that leads to social dependent change, as they are cultivated via how other individuals view the person. Expert power develops through being perceived as credible and trustworthy, while referent power is cultivated through being admired and well-liked (42). Informational power is considered a power that leads to socially independent change, as disseminating information between the power source and target requires acceptance of knowledge, which the target continues to absorb and apply on their own following knowledge exchange (43).

To outline how peer engagement with a clinical champion can reduce provider-level barriers to implementing EBPs and facilitate behavior-change, we apply two social-cognitive models, the Theory of Planned Behavior [TPB; (44)] and the Health Action Process Approach [HAPA; (45)]. The Theory of Planned Behavior [TPB; (44)] describes how an individual develops intentions to perform a specific behavior and posits that their motivation or intention to engage in a behavior impacts the likelihood of them doing so (44). Intention development is influenced by an individual's attitudes toward the behavior (i.e., individual's evaluation of the behavior), subjective norms (i.e., perceived social expectations or pressures to engage in a specific behavior), and their perceived behavioral control (i.e., perceived ability to adequately perform the behavior) (40, 46). Extending beyond intent and motivation, the HAPA model is a social-cognitive dual-phase model that describes the processes needed to transition from intent to action (47). The HAPA model contains two phases to explain executing a particular behavior: a motivational (intention formation) and volitional phase (planning for behavior enactment and action) (45, 48). A key component of the HAPA model is the distinction between individuals who are engaging in pre-motivational processes that lead to developing intent and those who are engaging in post-intentional volitional processes or behavioral enactment (45). During the motivational phase, an individual is considered a “pre-intender” as they are developing intent to adopt a new behavior (45, 49), similar to the TPB. Once intent is established, an individual enters the volitional phase, which is broken into two separate classifications, “intenders” (i.e., individuals intending to perform the behavior in question) and “actors” (i.e., individuals already engaging in desired behavior) (45). These unique stages of behavior change align well with the types of individual-level barriers providers face, which also can relate to developing intention to use EBPs (i.e., attitudes and knowledge) and deploying EBPs (i.e., planning) (4, 30).

These models were selected to inform the proposed causal pathways due to their relevance to understanding adult behavior change and their routine application in implementation science to address the research-to-practice gap (50–52). These theories clearly explicate individual-level factors that impact behavior change and can also account for the role of others within the implementation context, such as clinical champions, in influencing both implementation intentions and action (e.g., through social norms). These models also have been supported empirically (53–55). The TPB has been routinely used in previous implementation science research aiming to investigate clinical provider's intentions to adopt EBPs (2, 40). Additionally, the HAPA model provides a unique contribution beyond the TBP by also accounting for behavioral engagement and other factors that address the intention-behavior gap (56). Whereas other adult-focused behavioral change theories describe constructs that predict overall behavior intention, the HAPA model can also outline potential causal pathway mechanisms relevant to providers who actively transition from intention to behavioral enactment and then need to sustain that behavior enactment over time (51, 56).

Establishing hypothesized causal pathway mechanisms will advance our current understanding of how this specific implementation strategy, identifying and preparing clinical champions, influences provider delivery of EBPs. Understanding these mechanisms is crucial to advancing the scientific literature and will allow for better understanding of existing implementation strategies, strategy development, and appropriate strategy selection for use in specific implementation contexts (9, 10). The proposed causal pathways explain how clinical champions impact providers in various stages of the behavior change process: pre-intenders (i.e., those developing intent to perform the desired behavior), intenders (i.e., individuals intending to perform the behavior), and actors (i.e., individuals who have engaged in the desired behavior) (45, 49).

Clinical champions likely play a critical role in reducing provider implementation barriers for clinicians across various phases of behavior change (e.g., pre-intenders, intenders, and actors). Clinical champions promote the development of intention by displaying significant knowledge about the EBP, behavioral modeling of the EBP's utility, and establishing peer buy-in. In contrast, clinical champions aid intenders to transition into behavioral enactment through skill building which can promote sustained usage of the EBP. This paper contributes to the gap in scholarship outlining potential mechanisms of implementation strategies and can lead to future research testing such mechanisms.

AM devised the main conceptual ideas and outline, developed the pathway mechanisms, guided and supervised by LG, and drafted mechanisms figures with guidance from CL. AM and LG wrote the manuscript, with consultation and input from CL. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict ofinterest.

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