Background
Methods
The PECAN pilot trial
Study design of the process evaluation
The PECAN intervention
Process of change
Implementation strategy
Researcher-guided implementation steps
Facilitator-guided implementation steps
Standard care – the context
Study population of the process evaluation
-
the facilitators, responsible for the implementation of PECAN,
-
the nurses, who were introduced to the intervention by the facilitators,
-
additional persons, who were closely engaged in the care of residents with joint contractures, i.e., therapists, social workers and relatives,
-
and the research team, especially the trained peer-mentors, who were responsible for support of the facilitators during implementation.
Data collection
Domain | Research question | Research methods and measures | Participants | Stage of study |
---|---|---|---|---|
Delivery to clusters | What intervention is actually delivered to each nursing home? | Evaluation of the facilitators workshop using documentation forms | Research team | During and after each implementation component |
Evaluation of the information session using documentation forms | Research team | |||
Were the components of the implementation introduced as planned? | Evaluation of the peer-mentor-visit using documentation forms | Research team | ||
Evaluation of the peer-mentoring using documentation forms | Research team | |||
Response of clusters | How is the intervention adopted by the nursing homes? | Feedback on implementation components and process using standardised questionnaires, documentation forms, and facilitators’ diary | Facilitators | During implementation and post-intervention |
Are there any differences between the nursing homes? | Participants in the information session | |||
Research team | ||||
Are there any changes in daily nursing routine? | Survey using standardised questionnaire on experiences and perceived changes in attitude and behaviour | Nursing staff | At baseline and after 6 months | |
What are the enablers and barriers for a successful implementation? | Problem-centred interviews and group discussion to ask about experiences during implementation | Facilitators | Post-intervention | |
Therapists, social workers and relatives | ||||
Peer-mentors | ||||
Context | In what context is the intervention implemented? | Description of the wider context based on literature on national nursing home standards | Literature search | Before baseline |
Collection of important structural characteristics using structured cluster-interviews | Head nurse | At baseline | ||
How do contextual factors influence the implementation process? | Problem-centred group interviews and group discussion to ask about the influence of context-specific factors during implementation | Facilitators | Post-intervention |
Characteristics of nursing homes – the context
Process of implementation
Attitude and behaviour of nurses
Enablers and barriers of implementation
Data analysis
Results
Characteristics of nursing homes – the context
Intervention group | Control group | Total | ||||||
---|---|---|---|---|---|---|---|---|
Cluster 1 | Cluster 2 | Cluster 3 | Cluster 4 | Cluster 5 | Cluster 6 | Cluster 7 | ||
Study participants | 9 | 20 | 11 | 24 | 24 | 23 | 18 | 129 |
Participants levels of care dependencya | ||||||||
None | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 1 |
Low | 0 | 0 | 0 | 0 | 0 | 0 | 2 | 2 |
Considerable | 5 | 14 | 3 | 1 | 10 | 1 | 7 | 41 |
Severe | 4 | 6 | 6 | 8 | 11 | 9 | 7 | 51 |
Most severe | 0 | 0 | 1 | 15 | 3 | 13 | 2 | 34 |
Ownership b | private | private | church-owned | church-owned | non-profit | non-profit | private | |
Long-term care beds | 40 | 107 | 171 | 165 | 48 | 128 | 115 | 774 |
Nursing home wards | 3 | 4 | 4 | 6 | 2 | 4 | 6 | 29 |
Residents per ward | 13 | 27 | 43 | 28 | 24 | 32 | 18 | 27 |
Prevalence of joint contractures c | 0.40 | 0.96 | 0.19 | 0.21 | 0.50 | 0.31 | 0.60 | 0.28 |
Ratio of nursing staff to residents | ||||||||
Skilled nurses and assistants | 0.49 | 0.30 | 0.35 | 0.38 | 0.32 | 0.34 | 0.30 | 0.35 |
Skilled nurses | 0.28 | 0.16 | 0.19 | 0.20 | 0.17 | 0.16 | 0.16 | 0.19 |
Interprofessional case conferences d | regularly | occasionally | regularly | regularly | regularly | occasionally | regularly | |
Local environment e | ||||||||
Park areas | yes | yes | yes | yes | no | yes | yes | |
Stores (e.g. supermarket, drugstore) | no | yes | yes | yes | no | yes | yes | |
Churches | no | no | yes | yes | no | yes | yes | |
Coffee bars | no | yes | yes | yes | no | yes | yes | |
Environment promoting physical activityf | no | no | yes | yes | yes | yes | yes | |
Degree of urbanisation g | rural | urban | urban | suburban | suburban | urban | suburban |
Process of implementation
Cluster 1 | Cluster 2 | Cluster 3 | Cluster 4 | |
---|---|---|---|---|
Kick-off meeting | ||||
Meeting conducted according to protocol | ✓ | ✓ | ✓ | ✓ |
Declaration signed | ✓ | ✓ | ✓ | ✓ |
Facilitators’ workshop | ||||
Agenda and content according to protocol | ✓ | ✓ | ✓ | ✓ |
Number of trained facilitators | 2/2 | 2/2 | 4/4 | 6/6 |
Qualification for the role as facilitator | 2/2 | 2/2 | 4/4 | 6/6 |
Information session | ||||
Session conducted according to protocol | ✓ | ✓ | ✓ | ✓ |
Number of participants per session | ||||
Nursing staff | 0 | 2 | 11 | 11 |
Residents | 4 | 3 | 3 | 0 |
Relatives | 1 | 1 | 0 | 2 |
Others | 0 | 1 | 1 | 1 |
Missing | 0 | 3 | 1 | 1 |
Total | 5 | 10 | 16 | 15 |
Peer-mentoring | ||||
Peer-mentor visit | ||||
Agenda and content according to protocol | ✓ | ✓ | ✓ | ✓ |
Number of facilitators participating | 2/2 | 2/2 | 2/4 | 4/6 |
Participation of the head nurse | ✓ | ✓ | ✓ | ✓ |
Support by an external peer-expert | ✓ | ✓ | – | ✓ |
Peer-mentoring via telephone | ||||
Number of counselling interviews | 6 | 7 | 1 | 2 |
Number of facilitators counselled | 2/2 | 2/2 | 1/4 | 1/6 |
Interview duration in minutes, mean (range) | 85 (105–30) | 31 (75–10) | 10 (10–10) | 13 (10–15) |
Supportive materials | ||||
Project leaflets given to the nursing homes | 10 | 10 | 30 | 30 |
Specific leaflets for relatives, therapists, physicians given to the nursing homes | 35 | 40 | 21 | 21 |
Posters to promote physical activity given to the nursing homes | 3 | 3 | 4 | 6 |
Set of material for nursing team training | – | – | 4 | 7 |
Article for nursing home journal | – | – | 1 | – |
Facilitators’ diary | ||||
Response of the diary | 2/2 | 1/2 | 3/4 | 4/6 |
Monthly working time per facilitator in hours, mean (range) | 20 (20–20) | 5 (5–5) | 19 (17–20) | 5 (1–10) |
Categories | Enablers | Barriers |
---|---|---|
Overall strategy | • Stepwise training of facilitators (i.e., facilitators’ workshop, peer-mentor visit, peer-mentoring via telephone) (F) | • Lack of systematic involvement of all the different stakeholders (i.e., management, social workers, relatives, and therapists) (F, R, T, SW) |
• Clear defined PECAN content (F) | • Available time period too short to complete implementation (F) | |
• Personal contact initiated by the management or the facilitators to provide the different stakeholders with information on PECAN (T, F) | • Difficulties in the implementation for residents with severe physical and cognitive impairment (F) | |
Facilitators’ workshop | • Practical elements (e.g., training on the use of technical and medical aids) (M) | • Unbalanced ratio between theory and practice (i.e., more active participation during workshop required) (F, RT) |
Information session | • Use of plain language when addressing the different participant groups (RT) | • Lack of systematic involvement of the nursing staff (e.g., no presentation within the nursing team) (F) |
• Diverse groups of participants could be reached and informed about PECAN in one session (F, SW) | • Invitation to the session (i.e., poster at the entrance area) did not reached all potential participants (F, T, R, SW, RT) | |
Peer-mentoring | • The peer-mentor visit was highlighted as a useful introduction to the implementation of PECAN (F) | • Facilitators were usually not directly available via e-mail or telephone (e.g., appointments via the head nurse were necessary) (F, PM) |
• Continuous availability of the peer-mentors via telephone (F) | ||
• Standardised procedure of peer-mentoring via telephone (F, PM) - Routines for communication and regular appointments (F, PM) - Specific objectives based on the last counselling (PM) | ||
Supportive materials | • Supportive materials tailored for the target population (F, T, SW) - Training folder for facilitators (F) - Posters for the nursing wards (T, SW, F) - Materials for nursing team training (F) - Specific leaflets for relatives, therapists and physicians (F) - Article regarding PECAN published in nursing home journal (SW) | • Lack of supportive materials with a simple and practical design (F, R) |
• Lack of supportive materials to guide the implementation (e.g., no standardised documentation forms, no overview of potential intervention measures) (F) | ||
• Leaflets should have more focus on personal tasks (R) | ||
• Supportive materials did not reach the targeted population (R, T, SW) - Posters or other reminders in the nursing wards were not noticed (R) - Leaflets were not handed out (R, T, SW) |
Facilitator (F1, C1) about the practical part of the workshop:I had thought that maybe I would learn something new, [...] but that was not the case.
The information session was conducted in all clusters according to protocol. A total of 136 participants from seven nursing homes (intervention group n = 61; control group n = 75) attended the information session; 102 participants (range: 5 to 16 participants per nursing home) completed a questionnaire (response rate: 75%). Out of these 102 attendants, the proportion of nursing staff, residents, and relatives varied widely between the clusters (Table 3). Overall, the quality of the information session was rated with 1.9 points (SD 0.76; range: 1 to 4 points), indicating a good acceptance of the session. The statement by a relative points out why in some nursing homes external participants rarely receive information about the events taking place in the nursing home.What I liked very much was that someone from the medical supply store was there. I thought it was really good that he had said something too.
From the perspective of the facilitators, the session should have reached more nurses.[ … ] there's a bulletin board a little further back in the hall, but there are a thousand notes. I don’t really take notice of it.
Regardless of their participation in the information session, it became apparent that the content of the session was not detailed enough for the nurses. In the problem-centred interviews, some facilitators therefore suggested a short training session for all the nurses.There [should have been] many more employees, perhaps this should have taken place at a different time.
Peer-mentoring (peer-mentor visit, peer-mentoring by telephone, supportive material) was offered to all the nursing homes. Due to sick leave and vacation occurrences, four out of 14 facilitators were unable to participate during the peer-mentor visit. Overall, the peer-mentor visit was highlighted by the facilitators as a useful introduction to implementing PECAN.[...] the head nurse could already decide that [...] I can indeed explain what we have discussed - what the purpose of the intervention is - but to conduct a compulsory training session is a different matter [...]. For one or two hours.
During the visit the facilitators used a structured assessment tool to review organisational procedures and to develop tailored action plans to implement PECAN into their nursing home. In addition, case conferences were conducted at each visit, and individual care plans were developed for two residents to improve their participation. Support was given by the peer-mentor (all clusters) and an external peer expert (cluster 1, 2 and 4).It was especially interesting [...] at that time we introduced our residents, you [the researchers] also got to know our residents. That was really, really great.
Peer-mentor (P1):The mentoring by one of the researchers who continually inquired or provided incentives and motivations … it has always been quite good that there was someone else to ask.
All the nursing homes used the offered supportive materials, especially leaflets offering information on the PECAN intervention and the study procedure for relatives, therapists and physicians, as well as posters for promoting physical activity. Additional materials were used in accordance with the individual needs of the nursing homes (Table 3). The problem-centred interviews highlighted the impact to provide supplementary materials to support the implementation.What worked well was my commitment to my contacts. [...] I had defined clear communication paths and tools right from the start.
Facilitator (F8, C3):Yes, your information material was an advantage, we could hang up the posters. Well, someone always took a look at it.
The facilitators adopted various measures to implement the PECAN intervention in their nursing homes. The analysis of the facilitators’ diaries (n = 10 diaries returned out of 14) revealed that the following measures were conducted in all nursing homes: Adaptation of nursing records and care planning, development of an institution-specific guidance for managing joint contractures, inclusion of residents’ participation goals in case conferences with the nursing staff and the interprofessional team, counselling of colleagues and relatives, discussions with superiors, social workers, therapists and physicians, review of technical and medical aids, and environmental adaptations in the residents’ area and the nursing home. The documentation from the peer counselling and the problem-centred interviews provided better information about what was happening in the nursing homes.A special supplement for the documentation is missing.
Attitude and behaviour of nurses
Do you agree with the following statements? | Cluster 1 (n = 10) | Cluster 2 (n = 12) | Cluster 3 (n = 6) | Cluster 4 (n = 17) | Total (n = 45) | |||||
---|---|---|---|---|---|---|---|---|---|---|
n | (%) | n | (%) | n | (%) | n | (%) | n | (%) | |
I feel well informed about PECAN. | ||||||||||
Agree | 10 | (100) | 1 | (8) | 4 | (66) | 13 | (77) | 28 | (62) |
Neutral | 0 | 0 | 2 | (33) | 2 | (12) | 4 | (9) | ||
Disagree | 0 | 11 | (92) | 0 | 2 | (12) | 13 | (29) | ||
Supportive materials (e.g., posters, handouts, leaflets) on PECAN were provided comprehensively. | ||||||||||
Agree | 10 | (100) | 1 | (8) | 3 | (50) | 13 | (77) | 27 | (60) |
Neutral | 0 | 3 | (25) | 0 | 2 | (12) | 5 | (11) | ||
Disagree | 0 | 8 | (66) | 3 | (50) | 2 | (12) | 13 | (29) | |
The facilitators provided counselling whenever it was needed. | ||||||||||
Agree | 10 | (100) | 3 | (25) | 3 | (50) | 12 | (71) | 28 | (62) |
Neutral | 0 | 1 | (8) | 0 | 2 | (12) | 3 | (7) | ||
Disagree | 0 | 7 | (58) | 3 | (50) | 2 | (12) | 12 | (27) | |
Missing | 0 | 1 | (8) | 0 | 1 | (6) | 2 | (4) | ||
Overall, are you satisfied with the implementation of PECAN in your nursing home? | ||||||||||
Extremely / very satisfied | 10 | (100) | 1 | (8) | 4 | (67) | 12 | (71) | 27 | (60) |
Moderately satisfied | 0 | 2 | (17) | 1 | (17) | 5 | (29) | 8 | (18) | |
Not at all / slightly satisfied | 0 | 5 | (42) | 1 | (17) | 0 | 6 | (13) | ||
Don’t know | 0 | 4 | (33) | 0 | 0 | 4 | (9) |
Facilitator (F8, C3):[...] it was not at all possible [ … ] to realise the role as facilitator, i.e. the facilitator had the task after the training [...] of passing on the [contents of the intervention] to the colleagues. This was not successful at all in the larger institution. The support of the nursing home director was lacking.
To identify changes in daily routines due to the PECAN intervention, the nurses in the intervention group as well as in the control group were asked to rate statements towards organisational aspects that contribute to the residents’ participation (Additional file 1; Table A2). For example, in the intervention group, two thirds of the nurses (30/45, 67%) agreed (“strongly agree” and “agree”) with the statement “We often discuss how to improve the care of residents with joint contractures to enable them to participate in social life in the best possible way” at the 6-month follow-up, while less than half of the nurses agreed to this statement at baseline (22/51, 43%) or at the 6-month follow-up in the control group (17/36, 47%).In the role [as facilitator] I was able to assert myself better. I could say "Come, let's go to the resident and then you show me how you do it".
Enablers and barriers at the nursing home level
Categories | Enablers | Barriers |
---|---|---|
Personal factors | • Social relationships (F) - Respect and social support of facilitators by the nursing team (F) | • Social relationships (F) - Therapists perceive PECAN as an interference in their responsibilities (F) - Conflicting opinions and challenges within the interprofessional team regarding the care of residents with joint contractures (F, T) |
• Motives and motivation (F, SW, R) - Differing priorities of management and nursing team (F) - Poor motivation or little interest of the different stakeholders, i.e., nurses (F), physicians (F), therapists (F), social workers (SW) or residents (R) - Lack of interprofessional attitude among physicians (F) - Uncertainty and fear among relatives (e.g., additional costs, overburdening) (F) | ||
Organisational factors | • Clear commitment of the entire nursing home (F) - Active leadership to support changes (e.g., regularly occurring agreements and exchange, adoption of organisational tasks, approved time slots for meetings, provision of technical and medical aids) (F) - Open-mindedness to changes in the nursing team (e.g., review of residents’ care plans, implementation of measures to support participation, initiation of case conferences) (F) - Clear responsibilities within the interprofessional team (e.g., in collaboration with social workers, therapists and physicians) (F) | • Lack of impact on organisational conditions and routines (F, SW, T, R) - Unclear and unspecified responsibilities (F, SW) - Lack of interprofessional collaboration (e.g., little exchange, strict separation of working areas) (F, SW, T, R) - No established culture of contact and exchange between relatives and nursing staff (R) - No interprofessional case conferences (SW, T) |
• Respect for the expertise of different healthcare professionals and relatives (F, SW, T, R) - Respect for involved healthcare professionals (F, SW, T, R) - Recognition of various expertise and resources (T, SW, R) | • Lack of time and staff competences (F, R, T) - Staff shortage and high workload for nurses (F, R, T) and therapists (F, T) - No time slots for unscheduled tasks (F) - Skills shortage in the nursing staff (F, R, T) - Language barriers of the nursing staff (R) |
Facilitator (F12, C4):It’s hard... to really convince these die-hard nurses to actively participate, to implement, to think, to observe. That is difficult [...], and they must really want it.
As a fundamental precondition for a successful implementation, the clear commitment of the entire nursing home is required. This covers an active leadership in supporting the changes, open-mindedness to the changes, and clear responsibilities. These quotes from two facilitators illustrate how commitment can be experienced and, in contrast, how implementation stagnates if there is no commitment by the nursing home.Now something is happening here and I felt it was positive that we were practically involved. Half [of the nursing staff] could also have said “Oh, I don't feel like it” [...] or “I'm not interested in that here”.
Facilitator (F6, C3):We were always exempted from work for the meetings. For discussions, we got extra time. [...] It was a very, very close collaboration.
Moreover, a successful implementation is motivated by respecting the expertise of the different stakeholders, as emphasized in the following quote.I missed the togetherness [...]. I had talked to the head nurse after our workshop [...], but I had the impression ‘yes, that's nice you were here’ [...]. I missed the commitment and the interest.
A lack of impact on organisational conditions and routines was identified as a major barrier for the implementation. This includes unclear responsibilities and a lack of interprofessional collaboration which was impeded by the strict separation of working areas and the lack of an established culture of change. The subsequent quote by a therapist addresses the problem of the documentation.And I also have to say, the whole solidarity between us all, nurses, physical therapists, physicians, occupational therapists, this is now a really good collaboration, it works, you complement each other, you get tips.
A barrier that was reported as important across all clusters and from different stakeholders was a lack of time and staff competence, as illustrated by the subsequent quotes:[...] we have a documentation obligation as therapists. However, the documentation is run via our practice and not the nursing home. Well, I don't have to explain what I did in the nursing home, but that's normal.
Facilitator (F6, C3):Well, it’s not like I’m closed off to communication, for example. But very often it’s a time problem. That you don’t take enough time to share information or to communicate.
The major problem is of course the staff shortage, this is still known in many nursing homes [...] the time of course [...] whether management or staff, everyone has to do his work, is a bit stressed [...]