Sustaining complex interventions in long-term care: a qualitative study of direct care staff and managers

Focus groups (n = 15 groups) were conducted with 83 study participants in eight facilities following participation in CONNECT. Participants were purposefully selected based on their level of participation in the intervention and role in the facility (e.g., manager or direct care) to maximize diversity of perspective [11]; participants who had attended at least the first in-class session and were present in the facility on the day of the focus group were invited to attend. Focus groups were conducted within 1 month of the completion of the interventions. Group size was targeted at 8–12, and where possible, two separate focus groups were conducted with direct care workers and managers to optimize participant openness. Two study team members who were experienced in qualitative research and who had not been part of intervention delivery conducted the focus groups. Focus groups were convened in a private location (i.e., conference room) in the facility during regular working hours. All participants provided individual written informed consent. Ethics approval for this study was obtained from the Duke University Institutional Review Board, study number 18745.

Facilitators used an interview guide to elicit participants’ perceptions of whether and how CONNECT could be sustained in their facility. Interview guide questions and probes are listed in Table 1. Sessions were audio-recorded and professionally transcribed.

Interview transcripts were analyzed using ATLAS.ti [12]. Framework analysis, a systematic process for qualitative data analysis, was employed to identify core concepts emerging from the focus groups. This analysis approach is well suited for cross-sectional data [13, 14], is particularly useful in healthcare research as it allows for a priori concepts (e.g., salience, sustainability) [15] to be combined with inductive analyses, and creates an explicit audit trail in the data reductions within and between individual facilities and between analytic stages [15, 16].

The analysis proceeded in five stages: familiarization, identifying thematic framework, coding, charting, and mapping and interpretation. In the familiarization stage, transcripts of each focus group were created with names and site numbers redacted to blind coders to the identity of the participant and site. All team members read all transcripts. In the second stage, a thematic framework was identified. We had two a priori domains directly related to our research questions: salience, or the aspects of the intervention staff perceived as more or less impactful, and sustainability, or staff descriptions of whether and how the intervention could be continued after the end of the study. At a team meeting, preliminary codes were defined based on interview guide questions and probes (listed in Table 1) and initial reading of the transcripts. In the third stage, each of the transcripts was coded (i.e., indexed) by at least two team members using the a priori codes. In addition, open coding was employed for the first four transcripts and emerging themes were added in an iterative manner. In the fourth charting phase, we rearranged the data so that all quotes indexed with the same code were grouped together for each facility. The data were distilled during this step; for each coded quotation, a team member developed a brief summary statement, which linked the quote to the research questions. The charting process was repeated to synthesize the individual quote summaries into facility-level summaries (e.g., a summary of facility D’s quotes with the code “high impact”) and to create summaries for each code by manager and direct care focus group types (e.g., a summary of all manager group’s quotes with the code “suggested change”). At least two team members reviewed and validated the charting at each step. Disagreements were discussed during team meetings. Confirming and disconfirming evidence was sought from the primary data. In the final mapping and interpretation phase, we used the charts to describe key insights and compare them across facilities and group roles. For the presentation of findings, we took this highly synthesized set of findings from the mapping phase (step 5) and organized them using prior conceptual work by Scherier [1]. Scherier’s work suggests that sustainment of interventions that require coordination among multiple staff members is strongly influenced by three factors: characteristics of the intervention itself, factors within the organizational context, and external supports.

LTC staff reported that sustainable intervention content must be perceived to be effective and to promote organizational aims. Specifically, both direct care staff and managers across facilities reported being highly motivated to continue the behavior change when they perceived it would improve care for their residents.

RN: For me there are some people that are unapproachable…but this [program] just kind of helped me to approach them for the benefit of the resident…Even if I didn’t want to talk to that person I had to try to make it work so it would just be about the residents. So I liked how [the intervention] focused back on the residents.

The complexity of the intervention was also reported to influence how likely it was to be adopted and therefore sustained. The staff comments also highlighted the challenging balance for interventions targeting staff from a wide range of disciplines; a professional staff member in one facility reported that the intervention was too simplistic, while two nurse aides in another facility reported being confused about parts of the intervention.

SPEECH THERAPY: It was pretty basic, just kind of a review… I don’t think I got any new information or felt like I was inspired to do anything different.

NURSE AIDE: I’ve been very confused in the [class session] because I wasn’t told what the map was for…So I just randomly just gave some names because that’s what my instructions were to me.

Intervention delivery was reported to be important for its uptake and sustainability, with advantages and disadvantages perceived with different formats. Staff reported that group sessions allowed participants to learn from each other, build confidence about their importance to resident care, give “permission” to speak out about problems in the facility, and strengthen personal relationships. Role-playing was cited as a particularly effective delivery method within group sessions.

STAFF DEVELOPMENT COORDINATOR (SDC): You need to do the group thing… because everybody is going to have different opinions and you want people to listen and take something from that other person.

NURSE AIDE: I feel like I’ve gotten the confidence to build more relationship with whatever nurse I’m working with… I have more confidence to go to them, just by knowing that’s okay.

SOCIAL WORKER: And since [the group session]… I spoke out about some things that I didn’t think we’re doing quite well.

On the other hand, individual sessions allowed material to be customized and clarified and reinforced key concepts. Staff valued opportunities to practice and monitor new skills.

SPEECH THERAPY: I really liked keeping track of who I talk to because I would start to want to talk to them more and say “well I haven’t [used the intervention] with them yet.”

Staff across facilities emphasized that in the busy long-term care environment, the intervention needed to be customizable and flexible. They appreciated that sessions could be delivered in multiple locations and formats (e.g., multiple shorter vs. fewer longer sessions, classroom vs. nursing station) and worked around clinical demands.

SDC: You guys…did have an open schedule and that was good. And you did allow some variations with the timing with the people which was good. You just have to play it by ear. (Laughing) There is no set time, there is no set schedule because everyone is extremely busy and things come up.

In regard to educational materials, the participants encouraged development of visually appealing materials in different formats (e.g., print, video, online) to accommodate different learning styles. Non-nursing staff urged creating materials relevant to other types of roles in the facility (e.g., scenarios inclusive of dietary assistants and environmental service workers).

DIETARY DIRECTOR: Some of my staff, they did not sign up because most of the stuff was centered around nursing.

In the highly regulated LTC industry, staff warned that sustainability cannot occur when the program becomes just another mandatory training program or “chore.”

SDC: We’ve got a program now that all the staff has to do and I have to… make sure they’ve got it done…in a timely manner each month. So it’s just another chore. It’s not as much a learning situation as it’s a chore; “Oh I’ve got to get that done because [otherwise] I can’t work.”

However, suggestions for how to create appropriate incentives for sustainability were sparse. Several direct care staff members talked about creating “accountability” for participation by making participation mandatory.

NURSE AIDE: See, it was all voluntary. It wasn’t mandatory and so everybody was just “Okay, I’m not going since it’s just voluntary.”… If this was mandatory, maybe your point would get across and more people would participate.

A single social worker expressed the idea of changing organizational culture to sustain change but without specific suggestions on how to achieve it.

SOCIAL WORKER: Yeah and how we can hold ourselves accountable except for when we just came to the meeting? But when we were out [of the classroom] as a staff were we supportive of [the program] and was that part of our culture, do we take it into our culture?

In four facilities, staff agreed that an important part of sustaining the intervention was ensuring leadership support. In these facilities, direct care staff described a deep divide between managers and direct care workers that impacted whether or not the intervention was perceived as a priority.

SOCIAL WORKER: The leadership [needs to buy in]. NURSE AIDE: Right, ‘cause that’s how it is. The leader [has] got to lead for us to follow. They [are] just here for the money. We care more than them. SOCIAL WORKER: It’s normal to have attitudes [about your leaders] about where you’re working… A lot of time you feel like they didn’t really buy into it. So it really wasn’t a priority.

The CONNECT study provided a separate class for administrators and managers at the beginning of the intervention period, in an attempt to secure their early support and to prevent their presence from inhibiting direct care staff participation in classroom sessions. However, the fact that managers were not present with staff in the sessions was perceived as a barrier to uptake and sustainment because direct care staff concerns could not be aired and it appeared to them that managers lacked interest in the program.

NURSE AIDE 1: There were some nurses [in the session] but I think it would be helpful if we had like the Assistant Director of Nursing, Director of Nursing and possibly the Administrator. (Laughing in the room) NURSE AIDE 2: When we were doing [another class] we seen them in here but we didn’t see them when you guys were here though… NURSE AIDE 1: And there’s no possible way that ya’ll can get [the managers] together? Because that way they’ll be able to hear our concerns right in front of them.

Clearly, sustainability requires not only general leadership support for the program but also direct care staff seeing their active participation and prioritization. Interestingly, no discussion about the importance of leadership support occurred in the managers’ focus groups.

In response to questions about what type of support would help them to sustain the intervention in their facility, staff identified a number of processes and procedures that could be adopted. At least one facility reported changing their meeting and reporting structure to include more direct care involvement. Staff in most facilities considered adding CONNECT training to be a standard part of new employee orientation to address the issue of frequent staff turnover. Several facilities suggested adopting a “train the trainer” approach, where facility champions are identified to encourage continuation and conduct periodic refresher sessions.

RECEPTIONIST: I think this would be something good for orientation for them to go over… and a refresher because we do have in-services every month.

DIRECTOR OF NURSING: We need… a CONNECT champion that continues to keep people updated.

Tools that could support sustainment were suggested including posters or other visual reminders such as pens and calendars of bulletin boards. DVDs or video clips for staff who cannot attend a class were suggested. Orientation materials for new staff were suggested in all eight facilities given high staff turnover.

REHABILITATION DIRECTOR: Or a two minute [video clip] of a nurse coming in and dealing with a couple other staff members and somebody gets upset about something. Everybody goes off and [views it]. But then you [get together and ask] how could this scenario have changed?

Finally, creative use of information technology embedded in electronic health records was suggested as a means to keep the program fresh for staff.

NURSE AIDE: That’s what we have to do all of our charting [on the computers]. So if something like that popped up, a little in-service on there, we could…read it, ‘cause we have to chart. We’re probably there two or three times a day, at least.