Introduction
Background
Aim
Methods
Study design
Hasson’s conceptual framework for implementation fidelity
Implementation fidelity terms | Definition |
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Adherence | The measure by which implementation fidelity is assessed. This measure determines whether the intervention was delivered as intended [11]. The higher the fidelity, the greater extent to which the intervention was delivered as intended [11]. Adherence measurements are quantifiable and comprise of the following subcategories – content, frequency, duration and coverage [11] |
Moderating factors | A range of factors may impact the extent to which an intervention was implemented as intended [11]. According to Hasson, the following moderating factors have the potential to positively or negatively influence fidelity – participant responsiveness, comprehensiveness of policy description i.e. intervention complexity, facilitation strategies, quality of delivery, recruitment and context [30]. Participant responsiveness relates to how participants delivering as well as receiving the intervention perceive the intervention’s relevance and are engaged with the intervention [11, 30]. Intervention complexity relates to the description of the intervention [11] as well as the complexity of the intervention itself [30]. Facilitation strategies relates to the strategies employed to standardise and optimise implementation fidelity [11]. Quality of delivery relates to appropriate delivery of the intervention as intended [11]. Recruitment relates to the processes supporting participants to participate in the intervention [30]. Context relates to the structures, cultures and concurrent events which may impact intervention implementation [30] |
Adherence assessment
Moderating factors
Participants and data collection
Data analysis
Results
Adherence
Range of OSP intervention activities delivered
Random sample of 10% of medication reviews assessed for quality
Proportion of residents who received at least one medication review
Overall implementation fidelity rating
RACF | Range of OSP intervention activities delivered | Random sample of 10% of medication reviews assessed for quality | Proportion of residents who received at least one medication review | Overall score |
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1 | Yes | High | Medium | Medium – High |
2 | Yes | Medium | High | Medium – High |
3 | Yes | Medium | Low | Low – Medium |
4 | Yes | Medium | High | Medium – High |
5 | Yes | High | Low | Medium |
6 | Yes | High | High | High |
7 | Yes | Low | High | Medium |
Moderating factors
Profession | Number of participants | Age (years) | Gender | Professional experience (years) | Length of employment at RACF (years) | Prior aged care experience |
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On-site pharmacist | 6* | ≤ 40 (4, 67%) > 40 (2, 33%) | F (56, 83%) M (1, 17%) | ≤ 5 (1, 17%) ≥ 10 (5, 83%) | ≤ 1 (6, 100%) | Residential Medication Management Review experience (2, 33%) Supplying medications to RACF(s) experience (1, 17%) |
RACF manager | 8 managers** | ≤ 50 (2, 25%) > 50 (6, 75%) | F (6, 75%) M (2, 25%) | ≤ 15 (2, 25%) > 15 (6, 75%) | ≤ 1 (3, 37.5%) > 1 (5, 62.5%) | ≤ 4 (2, 25%) > 4 (6, 75%) |
Summary of key findings | Exemplary quotes |
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Intervention complexity
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It took time to work out how to deliver the OSP intervention |
when [the OSP] first started, we never had one, so we didn’t know what to do with [the OSP] when [the OSP] started… I would say, it took us probably about three months to really get into the swing of what we needed [the OSP] to really do. (M7.1)
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Facilitator: study resource folder |
having that information [in the study resource folder] … meant that we were all coming from the same idea that we want to be accessible, reduce medications where possible and rationalise them, and improve medication management from being on site. (OSP 7)
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Barrier: OSP job description |
There were too many items on the attached Position Description provided at the commencement of [their] contract to be realistic for two days per week. (M5.1)
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I didn’t feel I have a very clear job description. The facility didn’t know what my job was going to be either. (OSP 1)
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Facilitation strategies
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Facilitator: Pharmacist support meetings |
I love the three-monthly meetings… they’ve been really helpful just to reset and refocus and get a bit of guidance what to focus on next. (OSP 6)
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Quality of delivery
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Generally delivered to a high standard |
Two years ago at RACF 6, we were completely non-compliant with medications; we didn’t meet the standard at all. So I’m being honest here. So in the last year, having [the OSP] here, we’ve been able to become completely compliant… having a pharmacist to go to… you can actually see the difference with medication management, [it] has improved immensely. (M6.1)
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One exception – one OSP not able to offer vaccination services |
I know [the OSP] did try to get that credential [to be able to vaccinate], but [they] couldn’t find any courses that were available. That would probably be the only thing that would’ve been quite beneficial to us. (M7.1)
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Barrier: Part-time nature of OSP role |
I’m not always here when the GPs are here and I’m not always here when the changes are made. (OSP 7)
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It would have made an even greater impact if she was able to work more than two days per week to allow for greater follow up. e.g. if [the OSP] sent an email on Friday, [the OSP] could not follow up the response till the following Wed, five days later. (M5.1)
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Facilitator: Prior OSP experience |
[The OSP] had already started at another facility before [they] started here… so we implemented pretty much what [they were] already doing at that other one here… And it kind of worked really well in with what we wanted to do, anyway… So within a couple of weeks, [we] were just flying. (M6.1)
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Participant responsiveness
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Participants mostly perceived that OSPs in RACFs added value and OSP intervention should continue |
it’s just a very valuable resource [having the OSP] that would just only complement the clinical team and the workforce within the facility. (M2.1)
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But if they could see their way clear to fund [an OSP], I think it’d be a good outcome for every aged care [facility]. (M1.1)
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So I feel everyone is used to me being here and sees value in me being here and would like me to stay. (OSP 1)
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Participants [specifically RACF staff] were responsive |
They’re all like that if [the OSP’s] here, [the OSP’s] helpful. I felt that they go to [the OSP] if they need to and ask questions if they have to. (M3.1)
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‘Missed opportunities’: Limited OSP work day availability which contributed to delays in OSP intervention being delivered as intended |
I think we've got up to up to full-steam now over the last couple of months… [but] there was missed opportunity in the beginning which was no one’s fault… [which] slowed the [initial] uptake of engagement with the GPs. (M4.1)
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‘Missed opportunities’: Perceived limited impact of OSP intervention due to the OSP (who was not accredited) not focussing on medication reviews in their part-time role and relying upon RACF management to guide delivery |
But to actually – to really justify having someone, for us to take it on a permanent basis, I probably would have a hard time trying to explain it... I can’t see any real big fundamental changes that have been made. (M7.1)
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I think what we missed – the opportunity there was more deep dives into specific residents like where we were having residents who are having large amounts of falls or were particularly unwell (M7.1)
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And I think because the facility of our size … it’s a very big job, and I think it was just a too big a job for [the OSP] to be able to do in the hours that [they were] here. (M7.1)
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I think it would’ve been good for the [OSP] to actually have an idea or have them have a plan of they wanted to do to support us. I think a lot of the onus was put on us. (M7.1)
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‘Missed opportunities’: OSP not being able to vaccinate |
[Their] colleague in RACF 6 was a lot more – well, in that respect, was a lot more useful because when the flu vaccinations came about, [OSP 6] administered all the flu vaccinations to the staff. (M7.1)
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‘Missed opportunities’: Perceived limited capacity of the RACF manager to work with the OSP to further optimise OSP intervention delivery |
I think the busyness distracts me a lot where I could be working more with people like [the OSP] to look at how do we improve processes and systems. But I think there’s a real opportunity there that I probably missed or [the OSP] might’ve missed where we could do more work together. (M2.1)
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I think it’s an invaluable service that we’re now going to lose, having an onsite pharmacy expert just, as I said, as a quick reference point then to help us with our assessment and management of residents and their medications. (M2.1)
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it’s sad knowing that the role’s coming to an end because I think the longer [the OSP] would be here… [the more possible it would be] to see what else [the OSP] can do that would help us in our medication management. (M2.1)
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Context - OSP factors
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Facilitator: OSPs who took time to establish relationships and were pro-active in informing OSP intervention delivery |
So I think that would give an incoming [OSP] a big advantage later down the track and save a lot of time, if they do establish their role and those relationships as soon as possible. (OSP 6)
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So basically, I had to inject myself and say, “Look, I can take that workload from you. I can do that for you. I can help with that,” and really push a little bit at the beginning to say, "Look, I am actually here to help you and make your life easier." (OSP 1)
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And [the OSP] also said to us, “I feel like I could be of help here.” (M1.1)
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Facilitator: Experienced accredited pharmacists |
Well, I guess being accredited really helped… I think that without that, I would have had to get into the groove of reviewing medication charts. (OSP 3)
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Context – RACF factors
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Facilitator: RACF managers who actively supported OSPs |
As Care Manager I worked closely with our onsite Pharmacist and gave [them] a clear list of priorities each week that we would like [them] to focus on. (M5.1)
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[The OSP] was sitting down in the Aged Care Funding Instrument office [initially which meant that the OSP’s] not in any flow traffic, GPs [as well as residents and staff] weren’t able to easily access [the OSP]. So, I moved [the OSP] into my office… [and] I think we did get [the OSP]… more included into the facility… [and] more probably in the middle of it. (M7.1)
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Facilitator: Positive RACF culture |
The staff here and the residents here are all lovely. The staff are really putting their residents first. The attitude is very – it’s a family, we’re looking after each other, and they’re really supportive of each other as well and I feel like that flows through to the care and encourages me to care more as well, and do my best. (OSP 1)
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Barrier: RACFs spread out over a large area with significant distance between resident dwellings |
partly because of the way it’s set up … you stay in your bubble a lot more here than at the previous [RACF] which was all one big communal space… It’s not an organic thing here. I have to actually go to the [resident dwellings in this RACF which is spread out] and meet them and talk to them and all that which is a bit different. It is a much bigger facility as well. So getting to know particular residents really, really well has been a lot harder, whereas at the last facility, there were some residents that I saw every day that I was there and got to know really, really well. (OSP 6)
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Context – external factor
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Barrier: COVID-19 pandemic |
Look, it [the OSP intervention] came at a really tricky time of COVID-19… [we were] so busy focusing on compliance with COVID-19 monitoring requirements. (M4.1)
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So there was a bit of time [due to COVID-19] where it was difficult to talk to the residents… it was stressful a bit for the staff especially, and we had to wear masks all the time for a while, and some of the residents expressed frustration and difficulty seeing their family and all that. But my role as such, I was still able to do most of my tasks, it’s just the talking to people and to the residents, that was really restrictive. And to be honest, it’s taken a while to get back out of that habit. (OSP 1)
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