Domain | Construct | Primary issues identified |
---|---|---|
Intervention Characteristicsa | Â | Â |
 | Evidence, strength, and quality | Awareness of successful pre-existing ED-peer influenced adoption decisions for all vendors, but rural vendors were skeptical about applicability to their settings. |
 | Intervention source | |
 | Relative advantage | Rural vendors saw advantages of peers outside of the ED, where urban vendor solely focused on peer advantage in the ED. |
 | Adaptability | Rural sites made more adaptations over time to address peers’ low work volume. |
 | Cost | Rural vendors had greater concerns regarding costs. |
External contextb | Â | Â |
 | Target population | Rural vendors did not have resources to fully staff peak overdose admission times or the ability to engage with transferred patients. Patients in rural areas also tended to use drugs other than opioids. |
 | Relational climate | Rural vendor slacked protocols to follow-up with transferred patients. |
 | Policy and legal climate | Privacy laws limited rural vendors' ability to share information with other hospitals where patients were transferred. |
 | Local infrastructure | Rural areas lacked treatment providers for patient referral and options for transportation to referrals were limited. |
Inner settinga | Â | Â |
 | Networks and communication | Rural vendors lacked strong mechanisms for communication between ED staff and peers. Rural providers were often reluctant to have peers see patients. |
 | Culture | Rural peers frequently encountered lack of respect for their lived experience and negative attitudes toward addiction on the part of ED staff. |
 | Implementation climate | Rural vendor experienced difficulties justifying integration of peer services into ED systems and workflows due to low volume of patients eligible for peer services. |
Characteristics of individualsa | Â | Â |
 | Knowledge and beliefs | Rural providers resisted working with peers and patients they served due to pre-existing beliefs. |
Implementation processa | Â | Â |
 | Engaging | Rural vendors had to spend more time identifying external providers to refer patient to. They also spent more time engaging local law enforcement in order to create more work for peers. |
 | Executing | Rural vendors abandoned more components of their initial implementation plans because of staff resistance and low patient volume. |