Background
Methods
Design
RID intervention
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Researchers organized a kick-off meeting in the NH.
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NHs formed an MPT consisting of at least nursing staff, psychologist(s), physician(s), and an internal project leader. The MPT preferably included stakeholders, such as management and representatives of the residents. Each MPT was supported during their intervention period by an external coach.
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Throughout the process, the MPT and external coach had several meetings (total number was not pre-defined).
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Researchers carried out a problem analysis (both quantitative and qualitative data) using interviews and questionnaires. Problems (as perceived by NH staff) regarding inappropriate PDU and NPS management were examined (observation phase).
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Researchers presented the results of the tailored problem analysis to the MPT and external coach, which was followed by interpretation and reflection in the context of the local NH (reflection phase).
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The MPT and external coach created an AIP that matched the identified problems (planning phase).
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The external coach and researchers provided feedback on the AIP (relevance and feasibility of actions, concreteness).
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The MPT started by implementing the tailored AIP (action phase).
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Researchers carried out an interim measurement on inappropriate PDU. The eight MPTs that started as the intervention group were given interim results at 8 months (observation phase).
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The external coach and MPT discussed and reflected on the interim results (reflection phase).
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The MPT was able to adjust the AIP based on the interim results (planning phase) and implement any changes during the second period (action phase).
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Researchers carried out a final measurement with respect to inappropriate PDU and provided the MPT with their final results after 16 months.
Intervention quality and barriers and facilitators to implementation
INTERVENTION QUALITY | ||
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Relevance and Feasibility of RID Intervention | ||
Stakeholder | Indicator | Source |
1) Researchers | Added value tailored information provision | Questionnaire: Likert scale |
Experiences with researchers | Interviews: description | |
2) Internal project leader & MPT | Competence A of project leader (perceived by coach) | Questionnaire: Likert scale |
Experiences with project leaders | Interviews: description | |
Experiences with MPT | Interviews: description | |
3) External coach | Added value of coaching | Questionnaire: Likert scale |
Coaching necessity for (continued) implementation | Questionnaire: Yes/No | |
Competence A of coach (perceived by project leader) | Questionnaire: Likert scale | |
Experiences with coaching | Interviews: description | |
Extent of Performance of RID Intervention | ||
Task | Indicator | Source |
1) Organizing efforts of stakeholders | ||
- Researchers | Kick-off meeting in nursing home | Questionnaire: Yes/No |
- MPT | Formation of an MPT | Questionnaire: Yes/No |
Attendance physicians, psychologists, and nursing staff at MPT meetings B | Questionnaire: % attendance B | |
- External coach | Meetings coach and MPT in nursing home C | Questionnaire: # meetings |
(Phone) meetings coach and project leader C | Questionnaire: # meetings | |
2) Problem analysis | Researchers carried out problem analysis and presented results to the MPT and coach | Questionnaire: Yes/No |
3) Designing tailored AIP | AIP created | Questionnaire: Yes/No |
Contribution coach, project leader, and MPT to designing the AIP | Questionnaire: Likert scale | |
Perceived match between problems and actions | Questionnaire: Likert scale | |
Coach provided feedback on the AIP | Questionnaire: Yes/No | |
Researchers provided feedback on the AIP | Questionnaire: Yes/No | |
Adjustments to AIP based on feedback | Questionnaire: Yes/No | |
4) Implementation of tailored AIP | Start with implementation D | Questionnaire: # weeks passed |
Execution actions as intended: E Implementation score | Questionnaire: 10-point scale | |
5) Monitoring progression | Researchers carried out interim measurement and provided the MPT with the results * | Questionnaire: Yes/No |
6) Stimulating progression | Coach discussed and reflected on interim results with the MPT * | Questionnaire: Yes/No |
7) Adjustments to tailored AIP | MPT adjusted the AIP based on interim results F * | Questionnaire: Yes/No Interviews: description |
8) Providing final results | Researchers carried out final measurement and provided the MPT with the end results | Questionnaire: Yes/No |
Barriers and Facilitators to Implementation | Interviews: data structured with CFIR |
Data collection
Data analysis
Results
Internal project leader (n = 16) | External coach (n = 6) | ||
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Female, n (%) | 14 (88%) | Female, n (%) | 5 (83%) |
Function, n (%) | Education, n (%) d | ||
Elderly care physician | 5 (31%) | Health sciences | 2 (33%) |
Nurse a,b | 4 (25%) | Public administration | 1 (17%) |
Team leader c | 2 (13%) | Business economics | 1 (17%) |
Project employer | 2 (13%) | Health business Administration | 1 (17%) |
Policy advisor | 1 (6%) | Social sciences | 1 (17%) |
Quality and policy employer | 1 (6%) | ||
Training coordinator | 1 (6%) |
Intervention quality: relevance and feasibility of the RID intervention
Internal project leader N = 15 N, (%) | External coach N = 6 a N, (%) | |
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1) Researchers | ||
Added value tailored information provision b | ||
Strongly | 9 (60%) | 12 (75%) |
To a reasonable extent | 5 (33%) | 3 (19%) |
To some extent | 1 (7%) | 1 (6%) |
2) Internal project leader | ||
Competence of project leader c perceived by coach | ||
Competent or very competent | N.A. | 9 (56%) |
Not competent/not incompetent | N.A. | 3 (19%) |
Other d | N.A. | 4 (25%) |
3) External coach | ||
a) Added value of coaching b | ||
Strongly | 7 (47%) | 6 (38%) |
To a reasonable extent | 6 (40%) | 9 (56%) |
To some extent | 2 (13%) | 1 (6%) |
b) Coaching necessity for (continued) implementation | ||
Yes | 5 (33%) | 9 (56%) |
No | 7 (47%) | 4 (25%) |
I don’t know | 3 (20%) | 3 (19%) |
c) Competence of coach c perceived by project leader | ||
Competent or very competent | 11 (73%) | N.A. |
Not competent/not incompetent | 1 (7%) | N.A. |
Other d | 3 (20%) | N.A. |
Internal project leader: “The actions are self-created, which creates greater support. You can impose all sorts of things but that won't work. It really has to come from themselves, what they think might work.”
External coach: “They had project groups and those people were quite driven to get started. They definitely had a clear direction... and they acted on this as well.”
Intervention quality: extent of performance
Researchers: As intended, the researchers carried out a kick-off meeting in each NH.
External coaches: The number of meetings (Table 4, columns 1b and 1c) with the external coach and the MPT on location varied substantially between NHs (range 5–13), as did the number of (phone) meetings between the external coach and internal project leader (range 0–12).
NH | 1a) Atten-dance MPT | 1b) Meetings coach + MPT | 1c) (Phone)-meetings coach + PL | 3a) AIP * created | 3b) Contribution coach, PL, MPT in designing AIP | 3c) Adjustments AIP based on feedback | 4a) Start with implementation in weeks | 4b) Execution A actions of AIP as intended | 7) Adjustments AIP based on interim results |
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1 | 76–100% | 9 | 0 | Yes | (Very) large | Yes | Within 8 | 8.4 | Not necessary |
2 | 0–25% | 7 | 5 | Yes | (Very) large | Yes | Within 8–16 | 8.5 | Yes |
3 | 26–50% | 13 | 12 | Yes | (Very) large | Yes | > 16 | 5.4 | No |
4 | 76–100% | 7 | 3 | Yes | (Very) large | Yes | Within 8 | 7.0 | Yes |
5 | 26–50% | 9 | 7 | Yes | (Very) large | Yes | Within 8–16 | 6.4 | Yes |
6 | 26–50% | 5 | 4 | Yes | (Very) large | Yes | Within 8–16 | 7.9 | Not necessary |
7 | 51–75% | 8 | 3 | Yes | (Very) large | Yes | Within 8–16 | 7.9 | Yes |
8 | 26–50% | 11 | 12 | Yes | (Very) large | Yes | Within 8–16 | 6.3 | Yes |
9 | 76–100% | 9 | 8 | Yes | (Very) large | Yes | Within 8–16 | 7.0 | N.A. B |
10 | 51–75% | 6 | 2 | Yes | (Very) large | Yes | Within 8–16 | 3.4 | N.A. |
11 | 76–100% | 5 | 3 | No. | N.A. | N.A. | > 16 | 5.0 | N.A. |
12 | 26–50% | 7 | 2 | Yes | (Very) large | Yes | Within 8–16 | 6.8 | N.A. |
13 | 76–100% | 8 | 4 | Yes | (Very) large | Yes | Within 8 | 7.3 | N.A. |
14 | 76–100% | 5 | 7 | Yes | (Very) large | Yes | Within 8–16 | 7.8 | N.A. |
15 | 76–100% | 5 | 1 | Yes | Reasonable | No | Within 8–16 | 5.3 | N.A. |
16 | 76–100% | 7 | 10 | Yes | (Very) large | Yes | Within 8–16 | 6.3 | N.A. |
Barriers and facilitators to implementation
Intervention characteristics
Inner setting
Process
External coaches mentioned that there were variations between NHs, requiring that they customized their approaches to each NH. Often external coaches were perceived to facilitate implementation by providing structure and reflection, and in some instances, they “scaled up,” examined the internal dynamics, and tried to create engagement by addressing the need for change and the relative advantage. Nevertheless, staff in some NHs were perceived to remain reluctant despite these strategies. An issue was that the expectations of the project were not always in line with what was communicated. It was sometimes expected (mostly by internal project leaders, but also by a few external coaches) that the results of the problem analysis would yield manageable and directly applicable information, without the need for reflection and translation by the MPT and external coach (e.g., “what does this information mean?” and “what do we want to do?”). Also, some MPT members failed to engage in the project either because the external coach was treated as the main carrier of the project or because MPTs were not open to being coached.External coach: “She read all information about the project, was well prepared, and brought structure; she worked according to a fixed agenda, with notes and action lists. She asked about intrinsic motivation (why are you in the project team) and held them accountable … She was decisive and sought connection with relevant parties such as the policy advisor and manager.”
Although MPT members were generally very enthusiastic, this did not guarantee results because the ability to move forward was sometimes perceived as limited. According to respondents, overestimating the ease of implementing the innovations led some NHs to create AIPs that included either non-specific or excessive actions that could result in an unclear division of roles and responsibilities. Despite researcher feedback in which these concerns were stressed, no changes were made by the relevant MPTs.External coach: “I can be very facilitating, and I can be a guide, but the organization must act itself. I can't tell people what to do ... I can only advise ‘it is smart to do this’ or ‘you can choose from this and this and choose for yourself what fits your organization’ best.”