Operationalizing the Consolidated Framework for Implementation Research to build and support the lived experience workforce in direct health service provision

Abstract Background The involvement of people with lived experience (LEX) workers in the development, design, and delivery of integrated health services seeks to improve service user engagement and health outcomes and reduce healthcare gaps. Yet, LEX workers report feeling undervalued and having limited influence on service delivery. There is a need for systematic improvements in how LEX workforces are engaged and supported to ensure the LEX workforce can fully contribute to integrated systems of care. Objective This study aimed to operationalize the Consolidated Framework for Implementation Research (CFIR) using a rigorous scoping review methodology and co‐creation process, so it could be used by health services seeking to build and strengthen their LEX workforce. Search Strategy A systematic literature search of four databases was undertaken to identify peer‐reviewed studies published between 2016 and 2022 providing evidence of the inclusion of LEX workers in direct health service provision. Data Extraction and Synthesis A descriptive‐analytical method was used to map current evidence of LEX workers onto the CFIR. Then, co‐creation sessions with LEX workers (n = 4) and their counterparts—nonpeer workers (n = 2)—further clarified the structural policies and strategies that allow people with LEX to actively participate in the provision and enhancement of integrated health service delivery. Main Results Essential components underpinning the successful integration of LEX roles included: the capacity to engage in a co‐creation process with individuals with LEX before the implementation of the role or intervention; and enhanced representation of LEX across organizational structures. Discussion and Conclusion The adapted CFIR for LEX workers (CFIR‐LEX) that was developed as a result of this work clarifies contextual components that support the successful integration of LEX roles into the development, design, and delivery of integrated health services. Further work must be done to operationalize the framework in a local context and to better understand the ongoing application of the framework in a health setting. Patient or Public Contribution People with LEX were involved in the operationalization of the CFIR, including contributing their expertise to the domain adaptations that were relevant to the LEX workforce.


Discussion and Conclusion:
The adapted CFIR for LEX workers (CFIR-LEX) that was developed as a result of this work clarifies contextual components that support the successful integration of LEX roles into the development, design, and delivery of integrated health services.Further work must be done to operationalize the framework in a local context and to better understand the ongoing application of the framework in a health setting.
Patient or Public Contribution: People with LEX were involved in the operationalization of the CFIR, including contributing their expertise to the domain adaptations that were relevant to the LEX workforce.
client participation, co-creation, lived experience, patient involvement, peer, peer provision

| INTRODUCTION
4][5] Introducing LEX workers into service delivery, therefore, is a key step to establishing integrated systems of care.
Acknowledging the multiple terms and definitions associated with LEX workers across a range of disciplines, this research will refer to all peer roles where a person is formally employed in a nonclinical capacity to provide direct support to peers and whose LEX of a health condition or service use is one of the main qualifications for employment 6 -hereafter referred to broadly as LEX workers.People with LEX informing this work are those for whom their LEX is at the forefront of their contribution, noting that they will have many other experiences and skills.People with LEX can exist at various organizational levels, including but not limited to administration, management, policy, research, and education.Furthermore, people with LEX can take on many different roles in an organization, including roles where LEX is not explicitly defined in their role description.For the purposes of this research, LEX workers provide a health service where both the target and agent of the service have LEX of the health condition or health service, meaning the activities that are performed by a LEX worker occur at a peer-to-peer level and avoid power differentials.Nonpeer staff refers to administrative (i.e., nonclinical) and clinical staff in a health setting of which LEX is not a qualification of employment.Service users are people who access a health service (i.e., patients), and carers are people who care for or accompany service users.
The growing number of roles undertaken by those with LEX in health services has been identified as an essential and valuable component of service delivery. 7This trend has not been without challenges, including a lack of role clarity and professional credibility identified by both LEX workers and their counterparts (e.g., health professionals and administrative staff). 3,80][11] Other local frameworks exist in the grey literature, which focus on guiding the process of implementation (process frameworks).2][13][14][15] The systematic development of a determinant implementation framework is necessary to guide how the LEX workforce can be sustained across healthcare systems.In turn, this offers service providers the opportunity to expand the LEX workforce and deliver more integrated care.
Determinant implementation frameworks, such as the Consolidated Framework for Implementation Research (CFIR), can be used by service providers to plan and inform real-world implementation efforts. 16The purpose of the CFIR is to clarify terminology and assess the extent to which the implementation of an innovation is effective across a range of settings and contexts. 17The domains of the CFIR include the contextual components of the innovation-the intervention characteristics, inner and outer setting, and the characteristics of the people involved-and the process by which implementation is accomplished. 17,18As LEX roles continue to integrate into health service delivery and expand to other areas of health care, a determinant implementation framework can provide a systematic way to approach the introduction of LEX roles within health service provision.
Implementation science frameworks have been applied to discrete program evaluations but have not been used to inform implementation efforts across systems of care.Adaptations to the CFIR, such as using contextually relevant language, are essential to increase the applicability and usability of the framework and to fully operationalize the constructs within organizations wishing to better support and build a LEX workforce. 18Further, although co-creation processes have not been previously used to operationalize implementation science frameworks, co-creation aligns with the values underpinning LEX by encouraging the participation of people with LEX to influence healthcare services. 19,20This study aimed to operationalize the CFIR using a rigorous scoping review methodology and co-creation process, so it could be used by health services seeking to build and strengthen their LEX workforce.This process will generate actions organizations can take to ensure an effective approach to engaging a LEX workforce.Operationalizing the CFIR framework will, therefore, focus on the contextual components that support a successful LEX role, rather than evaluating a LEX worker whose value may be tainted by a lack of supportive organizational structures and policies.

| MATERIALS AND METHODS
A multifaceted approach was used to develop and refine the implementation framework of LEX workers in direct health service provision, including (1) a systematic scoping review of available literature, (2) the development of a preliminary framework, and (3) co-creation sessions with LEX workers and their nonpeer counterparts to refine the framework.This process followed Arksey and O'Malley's five-step scoping review framework and the optional sixth step of a consultation exercise. 21We used the findings from the scoping review to develop a preliminary framework, which informed the co-creation sessions as recommended by Levac et al. 22 The purpose of the co-creation sessions was to validate the findings from the scoping review, build on available evidence, and offer a higher level of meaning, context expertise, and perspective on the findings.
A similar method has been previously used to develop a testable conceptual framework to prospectively and iteratively identify the likely implementability of healthcare interventions. 23The process is further illustrated in Figure 1.

| Scoping review
A scoping review was chosen because it is best suited to map key concepts across the evidence base. 21The research question guiding the scoping review was: 'How are lived experience workers effectively involved in health service provision?'.A search strategy was developed in partnership with a university librarian and then adapted for each of the included databases: PsychINFO, PsychArticles, Scopus, and Informit (Supporting Information S1: Appendix 1).A systematic literature search of databases was undertaken on 16 July 2021 and 27 September 2022 to identify peer-reviewed studies providing evidence of the effectiveness of involving LEX workers and their roles and expectations in health service provision (Table 1).
Research focused on informal support (e.g., peer support groups or online networks) and nondirect support (e.g., administration, research, or formal education) was excluded.Studies that did not explicitly state the worker had LEX were also excluded.Due to the emerging and rapidly changing nature of the health workforce, the search was limited to the years 2016-2022.5][26][27] Two independent reviewers (A.C., Y. H., S. K.) screened titles and abstracts, then full-text articles in the Covidence platform. 28Disagreements that arose between the reviewers during screening were resolved by a third reviewer

| Development of the preliminary framework
We used the CFIR as a scaffold for the development of the framework to guide efforts to build and strengthen the LEX workforce in health service provision. 17,18The descriptive-analytical method was used to map findings from the scoping review to the relevant domains and constructs of the CFIR based on the descriptors for each domain and construct.Each study was assessed by one reviewer (A.C.) to determine whether the study reported on each F I G U R E 1 Scoping review methodology and co-creation process used to develop and refine the implementation framework of lived experience workers in direct health service provision.domain and construct of the CFIR.Relevant study results were compiled into each domain and construct and then summarized.
Another reviewer (M.M.) verified these assessments with disagreements resolved through discussion.LEX workers and their nonpeer counterparts were recruited from a state-wide suicide postvention service in Australia.The research team discussed the framework development process with the service's leadership team, including those with LEX, throughout the project.Workers were invited through internal networks to participate in a 1-h session via videoconferencing (Zoom).These workers were selected for the focus group because of their unique roles in skilled LEX positions.A mutually suitable time was decided upon, and people interested in participating were sent an email containing a description of the project alongside the preliminary framework 1 week before the co-creation session.The co-creation sessions involved semistructured discussions about their experiences in their roles and critical aspects of the implementation process.No demographic information was collected.During the co-creation session with LEX workers, discussions centered around the final domain of the CFIR, the implementation process, because there was no evidence of this domain in the academic literature.

| Co-creation engagement sessions
Discussions with nonpeer counterparts focused on the inner setting (Domain Three), including structural characteristics, relational connections, communications and implementation culture, and the individuals domain (Domain Four), including others who have supported or hindered the involvement of LEX workers in the organization.We utilized an online software (Miro) during the session to visually collaborate, share ideas, and engage with one another.
Following the co-creation sessions, the preliminary framework was revised and sent to LEX workers and their nonpeer counterparts via email.They had the opportunity to review the revised framework and provide any final comments until a consensus was reached.

| Scoping review
The systematic search retrieved 1002 studies.With 567 duplicates removed, 434 titles and abstracts were screened.A total of 166 fulltext articles were screened, and 72 studies met the inclusion criteria for the purposes of this review.Among the studies identified, threequarters (76%) were in the mental health setting.The other identified studies were in behavioral health (e.g., substance use or infectious diseases), chronic disease (e.g., diabetes or multiple sclerosis), and community health (e.g., homelessness or criminal justice).Most studies were conducted in high-income countries such as the United States (38%), Australia (24%), and European countries (17%).A diverse range of terms was used to describe LEX workers, of which the most frequent were peer worker (35%) and peer specialist (19%).

Inclusion criteria
Exclusion criteria • An individual was employed (paid/unpaid) to provide direct support to service users • People with lived experience were involved in providing education, conducting research, or informing policy • Described the effectiveness of involving lived experience workers or the experiences of lived experience workers in health service provision from the perspective of patients or service users, other health professionals and administrators, stakeholders, and lived experience workers themselves • Studies that focused on patient outcomes (e.g., effectiveness) as a result of incorporating lived experience roles • Lived experience workers applied experiential knowledge to support service users • Informal support where people shared personal stories in a peerto-peer capacity (e.g., peer support groups or online networks) • Lived experience of a health condition and/or service use was one of the main qualifications for employment in the lived experience role • Person providing service did not have lived experience • The person receiving service did not have lived experience • Peer-reviewed primary studies • Secondary or opinion sources (e.g., systematic reviews and editorials) • Published in English after 2016 • Non-English study published before 2016 (n = 15, 21%), over half (n = 8) reported statistically significant positive health outcomes associated with the involvement of a LEX worker.

| Development of the preliminary framework
The terms and descriptions of the original CFIR domains were adapted for the context of building and strengthening the LEX workforce in health service provision using the findings from the scoping review.The original CFIR has six domains, and the identified studies from the scoping review reported on four domains.There was no available evidence for the individuals domain (Domain Four) and the implementation process domain (Domain Six).Supporting

| Co-creation process
The LEX workers (n = 4) described the value of being involved during the entire implementation process, but some workers said they wished they had been more involved earlier in creating their role.
They expressed the importance of differentiating their role from other roles and the additional training required to fulfill their role.The LEX workers valued the presence of LEX across the organizational structure and the ability to link with other LEX workers to debrief and process their experience in the role.They described their role as dynamic and valued the pay increase, training opportunities, and supervision they received when their duties expanded throughout the implementation period.Being adequately remunerated was key to feeling valued as a staff member.LEX workers discussed the issues of retention, turnover, and being understaffed, and attributed this to the intensity of the role, highlighting the importance of boundaries and self-care.
LEX workers expressed that service users did not always understand their role and sometimes expected a clinical solution.At times, the service users perceived the LEX workers as volunteers, so they may have felt like they were burdening the LEX workers.The LEX workers attributed the misunderstanding to stigma and undervaluing LEX.However, the LEX workers did believe that service users appreciated them and the sense of validation and hope they received.
Being able to give feedback to the organization about their experience in the role and what the service users need was important to LEX workers.Different feedback methods included monthly check-ins with a peer mentor through an external organization, recurring meetings with managers, and optional debriefs following a session with service users.Some LEX workers found various modes of feedback helpful.
Overall, providing feedback and sensing that the feedback was taken on board was critically important to the LEX workers.framework can be used as a determinant framework and can be used alongside other frameworks for context-specific guidance. 16

| Key themes
Based on the findings from the scoping review, mapping available evidence to the CFIR domains and co-creation sessions, the key components to the successful integration of a LEX worker in a health setting were identified as (1) an organizational commitment to engaging people with LEX in the co-creation of the LEX role and how T A B L E 2 Operationalized CFIR for the implementation of a lived experience workforce-quick reference.Are there individuals within the organization with expertise in the implementation of a lived experience workforce?Is it feasible to hire someone with expertise in the implementation of a lived experience workforce to drive the implementation process?
Construct 5: Implementation leads Individuals who lead efforts to implement the innovation Implementation leads may be people in lived experience or nonpeer roles.
Who is a formally appointed internal implementation leader?Do the internal implementation leaders formally appointed with responsibility for implementing a lived experience workforce and overseeing their work value the integration of a lived experience workforce?
Construct 6: Implementation team members Individuals who collaborate with and support the implementation leads to implement the innovation, ideally including innovation deliverers and recipients Implementation team members may be people in lived experience or nonpeer roles.
Do the individuals who are dedicated to supporting the implementation of the lived experience workforce value the integration of a lived experience workforce?

| Engaging people with LEX in the co-creation process
[31] The importance of engaging LEX workers in the process of defining the scope of their role and in the development of interventions delivered are included in the innovation domain (Domain One) (Table 2).[34][35][36][37][38][39][40][41][42][43] In the co-creation sessions, nonpeer workers discussed difficulties filling the LEX role in certain areas due to local attitudes and stigma towards identifying as someone with LEX.Nonpeer workers found that partnering with external organizations whose focus is training and supporting LEX workers was helpful in the implementation process.Considerations of the external economic, political, and social context within which an organization resides are included in the outer setting domain (Domain Two) (Table 2).Although the implementation process was not explicitly identified in the evidence review, the importance of this was discussed during the co-creation sessions.To improve the translation of new knowledge into practice, optimize the implementation of health interventions, and enhance outcomes, the implementation process in the context of LEX workers can be mapped onto the four processes of co-creation: co-ideation, co-design, coimplementation, and co-evaluation. 44Table 3 demonstrates where the CFIR-lived experience domains and constructs Key points Operationalizing questions Construct 9: Innovation recipients Individuals who are directly or indirectly receiving the innovation From a service user and carer perspective, services provided by lived experience workers are acceptable and add value to their care.
Will the needs of the service user be accurately addressed by introducing a lived experience worker in the service delivery model?How will the lived experience role be communicated to the service user and distinguished from a nonpeer role?Domain Five: Characteristics of lived experience workers domain The dynamic interplay between lived experience workers and the organization within which they work and how that interplay influences individual or organizational behavior change.
Construct 1: Attitudes Lived experience workers' attitudes towards and value placed on their work The perceived value that lived experience workers add to service provision fuels their own recovery journey.Lived experience workers can also perceive the value of their work to the organization through the remuneration they receive.
Does the lived experience worker believe their work adds value to the service model?Does the lived experience worker believe their work fuels their own recovery journey?How do we indicate to the lived experience worker their value to the organization?
Construct 2: Self-efficacy Lived experience workers' belief in their capabilities to execute courses of action to achieve goals The lived experience worker's role can be intense and requires boundaries and a self-care routine.
Does the lived experience worker have the necessary tools to establish boundaries in their role and a self-care routine?
Construct 3: Self-disclosure Construction of a positive identity through self-disclosure of lived experience as the lived experience worker progresses towards skilled, enthusiastic, and sustained use of lived experience Constructing a positive identity through selfdisclosure is a cornerstone of the lived experience role.This must be an ongoing process and can be constructed through training.
Does the lived experience worker engage in selfdisclosure?Is the lived experience worker able to construct a positive identity through self-disclosure of their lived experience?What trainings exist to support lived experience workers in constructing a positive identify through self-disclosure?Construct 4: Boundaries A broad construct related to how lived experience workers perceive themselves outside of their role and their ability to set boundaries between their personal recovery and others' recovery journey Lived experience workers must also create an identity outside of their lived experience and set boundaries with service users.
Is the lived experience worker able to set boundaries between their personal recovery and their role?Is the lived experience worker able to set boundaries between themselves and the service users?
Abbreviation: CFIR, Consolidated Framework for Implementation Research.
| 11 of 16 T A B L E 3 Operationalized CFIR for the implementation of a lived experience workforce domain six mapped to the co-creation process.

| Lived experience representation
The scoping review and co-creation sessions highlighted, that for people with LEX to actively participate in the provision and enhancement of service delivery, there must be representation of the values of LEX within organizational policies and practices and representation of people with LEX across the organizational structure.Organizational structures lacking representation and recognition of LEX were reported as oppressive to LEX workers. 45is resulted in LEX workers feeling undervalued and impeded their ability to provide support. 469][50] Because staff members' attitudes toward LEX workers were reported as being influenced by agency policies and programmatic rules, 47 clear policies and procedures were identified as necessary to provide adequate resource allocation and ongoing training to address workplace stigma. 32For example, additional training may be necessary for nonpeer workers in the values that underpin lived experience. 45Structural policies and processes, such as supervision and training, are included in the inner setting domain (Domain Three) (Table 2).These findings were further validated in the co-creation session with people working alongside LEX workers, who requested further training to adequately support LEX workers in their roles.
The integration of LEX workers into an organization required the encouraged participation of LEX workers in staff meetings as well as organizational structures that allowed for LEX workers to collaborate with other staff members. 38,42,47Being a part of an interdisciplinary team was reported as a necessary component and positive experience related to the integration of LEX workers into an organization. 40,47,51Further, consultation and collaboration among LEX workers and other nonpeer staff was an effective way of addressing stigma in the workplace 10 and assisted in the development and facilitation of effective programs and interventions. 42In work environments where LEX workers shared experiential knowledge, LEX workers were able to challenge the dominant ways of working and influence service delivery. 42,43,52,53The individuals domain (Domain Four) includes the various roles and characteristics of individuals involved in the implementation process, and the characteristics of lived experience workers (Domain Five) describe the interplay between LEX workers and the organization (Table 2).Lived experience workers act as agents of person-centered care, upholding values of recovery and agency amongst service users. 42,52Thus, the representation of LEX within an organization in addition to the structural policies that uphold the values of LEX becomes the impetus toward person-centered, integrated models of care.

| DISCUSSION
Implementation science frameworks are increasingly used across a range of contexts to enhance the implementation of health innovations.In particular, the CFIR has been adapted for diverse innovations and settings to identify barriers and facilitators to implementation outcomes. 18Recent (2022) updates to the CFIR highlight the need for users to fully operationalize constructs by adapting and using language that is meaningful for the context and individuals involved in implementing and delivering the innovation. 18is study aimed to operationalize the constructs of the CFIR using a rigorous scoping review methodology, 21 including co-creation sessions, so it can be used by health services seeking to build and strengthen their LEX workforce.Although there may be additional   2 and 3).Using the framework to design service strategies to establish and grow the LEX workforce will ensure that a holistic and evidence-informed approach is taken to increase the likelihood of positive outcomes.
The key components to the successful integration of a LEX worker in a health setting were: (1) an organizational commitment to engaging people with LEX in the co-creation of the LEX role and how interventions could be delivered; and (2) organizational representation of people with LEX.
This framework was developed through a co-creation process.
Co-creation is an ongoing collaborative process that allows LEX workers to develop and design their roles within the organization while representing the patient's voice in the co-production of care.
LEX workers involved in the co-creation sessions described the importance of providing feedback to the organization about their experience in the role and what the service users need.This was valuable because it allowed them to influence and improve service delivery and promote integrated care.This finding suggests that some of the barriers experienced by LEX workers contributing their experiential knowledge to the service and influencing healthcare practices and policies may be addressed through co-creation processes.Furthermore, the successful engagement of a LEX workforce within an organizational setting occurs when LEX exists at all levels to impact service quality in terms of accessibility and patientcenteredness. 5,11,54,55 The LEX workers involved in the co-creation sessions valued the presence of LEX across the organizational structure and the ability to link with other LEX workers for support.
Healthcare systems increasingly rely on the contributions of service users to share information, competencies, and skills with service providers to co-create value, 19 and this study identified LEX workers as potential facilitators of this co-creating partnership in direct service delivery.
This study highlights that despite the popularization and formalization of peer roles in health service delivery, 9 LEX roles remain undervalued.Current healthcare policy is informed by public health research operating within the context of evidence-based medicine, which places the views of service users below randomized controlled trials in the hierarchy of evidence. 56This may lead to the perception of the introduction of LEX roles in a health service as either tokenistic or unfounded.Challenging the biomedical model of care at an organizational level requires ongoing investment in training for LEX workers to gain experiential knowledge-the integration and translation of LEX 54 -and for nonpeer workers to understand the value of experiential knowledge in health service delivery.Ensuring a structured approach to the engagement of new workforces, with a framework to assess progress, is essential to achieving integrated systems of care.

| Strengths and limitations
The multifaceted approach to the development of a framework, including a rigorous scoping review methodology and wellestablished co-creation process, was a key strength of this project.
The co-creation process enabled LEX workers and their nonpeer counterparts to validate the findings from the scoping review, build on available evidence, and contribute their expertise and perspective on the findings.Embedding LEX voices in the framework development process was a key mechanism to operationalizing the framework.However, there were some limitations.There are limitations associated with the time period of the review (2016-2022), such as excluding fields of health care where peer support has been naturalized (e.g., disability support 57 ).Yet, this time period captures the dynamic state of LEX roles as reflected in the recency of international healthcare policies for the institutionalization of peer support in health services. 58,59The co-creation process was limited by the recruitment strategy, with only one organization represented, and only one session with LEX workers, and one with their nonpeer counterparts.We also did not collect demographic information, so it is possible that others would have similar and different views to those presented in these sessions.The organization had recently (within 2 years) established a LEX workforce, so we believe the co-creation findings are applicable to other organizations planning to involve LEX workers.We recommend future researchers consider recruiting widely across various university and community networks and budgeting appropriately for planning and executing cocreation sessions including compensation for people's time and efforts.We also point researchers to recent work on capturing and analyzing demographic data to ensure diversity of participation and transferability of findings. 60In light of these limitations, further research is required to corroborate the usefulness of this framework and the use of this framework in the context of people with LEX working in other roles such as administration, management, policy, research, and education.

| CONCLUSION
The (A. C., Y. H., S. K.).Reviewers met after each stage in the screening process and engaged in a reflexive discussion, as the terms and definitions used to describe LEX workers varied extensively.Two reviewers (A.C., Y. H.) independently extracted data from each study included in the review and examined the other reviewers' data extraction process.Reviewers met intermittently throughout the data extraction process to modify and revise the tool as necessary.The finalized data extraction form is presented in Supporting Information S1: Appendix 2.
Two co-creation focus group sessions were conducted in October 2022.The purpose of these sessions was to validate findings from the available literature and to identify other key concepts in the development and growth of a LEX role.The first co-creation session was held with four LEX workers, and the second session was held with two people who work alongside LEX workers ('non-peer counterparts').Ethical approval was granted by the University of New England's Human Research Ethics Committee (Approval No. HE21-224).
The definitions used to define a LEX worker included the following components: (a) provides support; (b) has LEX; (c) has completed formal training; (d) embodies the values of LEX and (e) works within a team.Most studies (n = 57, 79%) qualitatively explored the integration of LEX workers into a health setting and the associated challenges, benefits, roles, and expectations.Among studies that reported quantitatively on the effectiveness of LEX roles T A B L E 1 Inclusion and exclusion criteria.

Information S1 :
Appendix 3 provides a narrative summary of the literature relevant to each domain.Key aspects of the innovation domain (Domain One) covered in the literature included the value of having a LEX workforce from the perspectives of service users, nonpeer staff, and LEX workers themselves.The literature related to the outer setting (Domain Two) covered the challenges associated with external policies governing and formalizing LEX workforces.The organizational structures that promote and hinder the effective integration of LEX workers, including supervision and organizational representation of LEX, were covered in the literature related to the inner setting (Domain Three).The literature related to the characteristics of LEX workers (Domain Five) described the core and peripheral components of a LEX worker's role.
Topics discussed with nonpeer counterparts (n = 2) included the distinct value of LEX to service provision and needing a framework to guide the development and growth of a LEX workforce.Nonpeer counterparts described difficulties recruiting a LEX worker due, in part, to the stigma that exists towards people with LEX in the community.Similar to the LEX workers, they also discussed the importance of having people with LEX at various levels within an organization and having training available for those providing support to LEX workers.Nonpeer counterparts also identified some of the key individuals involved in the successful implementation of the LEX workforce.Findings from the co-creation sessions are further described in Supporting Information S1: Appendix 3.

3. 4 |
Fully operationalized CFIR for the implementation of a LEX workforceUsing the information from the co-creation sessions with the findings from the scoping review, we operationalized the CFIR-LEX framework.This adapted CFIR provides guidance about the structural policies and strategies that allow people with LEX to actively participate in the provision and enhancement of integrated service delivery across all domains.The CFIR-LEX domains one through five are described with short definitions and operationalizing questions in Table2.These domains include the following: the characteristics of the innovation being implemented (Domain One); external economic, political, and social context (Domain Two); internal structural, political, and cultural context (Domain Three); and roles and characteristics of those involved in the implementation process (Domains Four and Five).The implementation process is the sixth and final domain of the CFIR and consists of the stages of the implementation of an innovation in an organization, or the process by which implementation is accomplished.The operationalizing questions are presented to assist those using the framework to consider relevant aspects under each domain.This implementation

Construct 7 :
Other implementation support Individuals who support the implementation leads and/or implementation team members to implement the innovation External change agents may exist outside of the organization and formally influence decisions surrounding the implementation of lived experience workers.What other adjacent organizations have implemented a lived experience workforce?How can we partner with these organizations and external change agents to support and expand the lived experience workforce?Construct 8: Innovation deliverers Individuals who are directly or indirectly delivering the innovation The core component of a lived experience workers' role is direct support to service users.Periphery components can include indirect support such as managerial roles, teaching skills, and systems-level advocacy.Are lived experience workers' core competencies to deliver direct services?What are the periphery components of the lived experience workers' role?interventions could be delivered; and (2) the need for representation of people with LEX within an organization.These components were key themes identified by the authors across the various stages of the framework development process.
considerations for discrete organizations or initiatives, this current study aimed to develop a usable implementation framework for organizations who want to begin integrating a LEX workforce.We recommend organizations wishing to use the framework to guide how they engage and support LEX workers conduct further cocreation to ensure the applicability and usability of the framework within their local context.Recent popularization and formalization of LEX workforces globally require robust, evidence-based frameworks to ensure organizations can effectively introduce and support workers in these roles.The extended CFIR framework, CFIR-LEX, can be used by researchers and service providers to ascertain the barriers and facilitators of involving LEX workers in health service provision, improve the integration of LEX workers into service delivery, ensure the safety and sustainability of workers, and expand the workforce to other crisis and recovery services.The domains of the CFIR-LEX T A B L E 3 (Continued) active engagement of people with LEX in the co-creation process and representation of LEX across the various levels of an organization are the critical forces necessary to shift away from a traditional medical model of healthcare towards a person-centered, integrated care model.As the state of the LEX workforce expands across healthcare systems, the operationalized CFIR for the context of LEX workers functions as a useful and evidence-based tool for researchers to identify barriers and facilitators of the engagement of LEX workers and for service providers who wish to introduce a LEX workforce into their service model.AUTHOR CONTRIBUTIONS Alayna Carrandi: Conceptualization; data curation; formal analysis; writing-original draft; methodology; investigation; project administration; Document the innovation being implemented and distinguish the innovation from the implementation process.The outer setting refers to the economic, political, and social context within which an organization resides.The inner setting includes features of structural, political, and cultural contexts through which the implementation process will proceed.The roles and characteristics of individuals involved in the implementation process.
Construct 4: Innovation adaptabilityThe degree to which the lived experience role can be adapted, tailored, refined, or reinvented to meet the needs of the organization and service usersEngaging lived experience workers in generative activities allows them to tailor the service to meet the unique needs of the service user and fit the local context.Is the role of the lived experience worker flexible?Is the role of the lived experience worker and the activities delivered by the lived experience worker able to be adapted to suit local needs and service users?
The essential activities and strategies used to implement a lived experience workforce.