Fidelity and clinical competence in providing IMR 149 aggregated study results two or three times per supervision group up to that point. Subsequently, recommendations for the improvement of poorly implemented elements were discussed, as were ways to achieve these improvements. In addition, this fidelity feedback was provided in plenary sessions for all stakeholders per institution. The IMR groups were ranked by total scores on both the IMR Fidelity Scale and the IT-IS. A high group score on the IMR Fidelity Scale was defined as ≥ 4. Because the IT-IS has no predefined cut-off for group-level total scores, we used the cut-off scores at the item level for this purpose: 1 to < 2: unsatisfactory; ≥ 2 to < 3: needs improvement; ≥ 3 to < 4: satisfactory; ≥ 4 to <5: very good; 5: excellent. For both the IMR Fidelity Scale and the IT-IS, items were ranked across all groups in descending order of mean scores to explore which critical elements were implemented well and which were not. In addition, for the IMR Fidelity Scale per item, the percentage of groups with high scores was calculated. A high item score was defined as ≥ 4, a moderate item score as ≥ 3.0 to < 4.0, and a low item score as < 3. For the IT-IS per item, the percentage of groups with scores of satisfactory and higher was calculated. Analysis First, we described which IMR elements were measured by each of the two instruments. Second, descriptive statistics per IMR group were utilized to investigate the overall IMR fidelity (mean score of the IMR Fidelity Scale) and competency (mean score of the IT-IS). Third, descriptive statistics per IMR element and scale were utilized to investigate item-level fidelity. Fourth, the IT-IS indicators of excellence were used to examine the elements scored in the needs improvement and the unsatisfactory range in detail. Pearson’s correlation coefficient was used to measure the association between total scores of the IMR Fidelity Scale and the IT-IS. Three categories were applied in our interpretation of correlations: weak (0.1, 0.3), moderate (0.3, 0.5), and strong (0.5) (37). SPSS 27 was used for data analysis. The study protocol was approved by the accredited medical ethics trial committee at Erasmus University Medical Center Rotterdam (27/8/2012, METC nr NL38605.078.12) and is registered in the Netherlands Trial Register NL4931 (NTR5033). The authors declare that they have no conflicts of interest.
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