Chapter 6 156 to the IT-IS’s greater focus on clinical competency elements, which are harder to achieve than structural elements. In addition, the IT-IS incorporates more operationalizations and conditions to fulfill, including indicators of excellence. Therefore, we suggest that the IT-IS scale is largely complementary to the IMR Fidelity Scale but also more rigorous in its assessment of implementation quality. In this study, we found that the extended operationalizations of the IT-IS provided precise direction for needed additional IMR implementation support. However, in our view, the addition of the three missing structural items of the IMR Fidelity Scale (program length, provision of educational handouts, and number of people in a session or group) would make the IT-IS more complete. Furthermore, splitting the IT-IS “goals” item into “goal setting” and “goal follow-up,” as in the IMR Fidelity Scale, might also improve the usability of the IT-IS. The rating procedure of the IT-IS in this study was different from the original intent because extended interviews with IMR participants and trainers of each IMR group and chart reviews were employed to review, per IMR element, the specific behavioral characteristics for clinician competence in sessions in addition to the ones observed. By using this method for collecting fidelity data, we suggest that we were able to attain the required specificity. Both scales address fidelity through adherence to the IMR model (20, 32, 39). To this end, both scales address more clinical than structural elements. We suggest that clinical elements address clinical competency. Therefore, it appears that both scales aim to address fidelity more through the clinical competence of IMR trainers than through the application of structural IMR elements. Comparing results with other studies In this study, assessed with the IMR Fidelity Scale, average fidelity was slightly lower than the weighted mean of six studies reported in an IMR review (M = 4.05, SD = 0.93) (18). This might be partly due to the relatively high degree of refinement of the applied assessment procedure because, in this study, the assessment procedure included all components of the protocol (24, 35). Measured using the IT-IS, the average fidelity was also lower than that in one RCT (12). However, it was markedly higher than in another study on implementing IMR in community practice (36). Our results regarding the implementation levels of the different elements measured with the IT-IS are largely in line with the results of one previous study (36). Although fidelity in this earlier study was lower overall, the ranking was similar: the five elements with the lowest fidelity—medication management, weekly action planning, action plan follow-up, cognitive-behavioral techniques, and significant
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