Process Evaluation of a Participatory, Multimodal Intervention to Improve Evidence-Based Care in Long-Term Care Settings

The Required Competencies of Bachelor- and Master-Educated Nurses in Facilitating the Development of an Effective Workplace Culture in Nursing Homes: An Integrative Review

BACKGROUND

Nursing home care is undergoing significant changes. This requires innovative teams operating in an effective workplace culture characterized by person-centeredness and offering evidence-based care. A pivotal role for bachelor- and master-educated nurses (BNs/MNs) is foreseen to facilitate such cultures; however, there is currently no comprehensive overview of what competencies this requires.

OBJECTIVES

To identify what competencies are required from BNs/MNs in facilitating the development of an effective workplace culture in nursing homes.

METHODS AND DESIGN

We conducted an integrative review (IR) using Whittemore and Knafl's method. We searched the PubMed, CINAHL, and PsycINFO databases for studies published between January 2010 and December 2021 in English. Two independent reviewers determined whether studies met inclusion: bachelor- or master-educated nurse; nursing home; professional competencies; and mixed methods or qualitative and qualitative studies. We applied the CASP appraisal tool and analyzed the data by applying content analysis.

RESULTS

Sixteen articles were included. Five themes were identified representing required competencies for BNs/MNs facilitating: (1) learning cultures in nursing practice; (2) effective work relationships within teams; (3) leadership capability within teams; (4) implementation of guidelines, standards, and protocols; (5) a work environment acknowledging grief and loss of residents within teams.

CONCLUSIONS

It shows that the BN/MN applies five competencies associated with a facilitator role to promote the development of an effective workplace culture to achieve a safe, high-level quality of care, satisfaction, and well-being. An overarching leadership as a change champion will support teams to achieve a quality that should guide the transformation in nursing care.

Contextual factors influencing complex intervention research processes in care homes: a systematic review and framework synthesis

Background

Care homes are complex settings to undertake intervention research. Barriers to research implementation processes can threaten studies’ validity, reducing the value to residents, staff, researchers and funders. We aimed to (i) identify and categorise contextual factors that may mediate outcomes of complex intervention studies in care homes and (ii) provide recommendations to minimise the risk of expensive research implementation failures.

Methods

We conducted a systematic review using a framework synthesis approach viewed through a complex adaptive systems lens. We searched: MEDLINE, Embase, CINAHL, ASSIA databases and grey literature. We sought process evaluations of care home complex interventions published in English. Narrative data were indexed under 28 context domains. We performed an inductive thematic analysis across the context domains.

Results

We included 33 process evaluations conducted in high-income countries, published between 2005 and 2019. Framework synthesis identified barriers to implementation that were more common at the task and organisational level. Inductive thematic analysis identified (i) avoiding procedural drift and (ii) participatory action and learning as key priorities for research teams. Research team recommendations include advice for protocol design and care home engagement. Care home team recommendations focus on internal resources and team dynamics. Collaborative recommendations apply to care homes’ individual context and the importance of maintaining positive working relationships.

Discussion

Researchers planning and undertaking research with care homes need a sensitive appreciation of the complex care home context. Study implementation is most effective where an intervention is co-produced, with agreed purpose and adequate resources to incorporate within existing routines and care practices.

Developing an Evidence-Based Nursing Culture in Nursing Homes: An Action Research Study

Background: Nursing homes face challenges caused by increasing numbers of older adults with multimorbidity and the demand for quality of care. Developing an evidence-based nursing (EBN) culture is a promising strategy to face these challenges. Therefore, the aim of this study was to develop an EBN culture in nursing homes and gain insight into the influencing factors. Methods: An action research study was conducted with 12 nursing teams in 4 Dutch nursing homes, using the Practice Development approach to develop an EBN culture. The teams (mostly certified nurse assistants) were coached by internal facilitators (bachelor’s or master’s degree nurses) and external facilitators (nursing teachers). Data were gathered at baseline and after 15 months using questionnaires and individual and focus group interviews. Results: With varying degrees, most nursing teams implemented elements (related to values, attitudes, and behaviors) of an EBN culture with appropriate leadership, advocacy, and training. The team members became open to new insights and asked critical questions. During the project, participants learned how EBN could be incorporated into daily practice, for example, by keeping it small, discussing information from professional journals, and using creative methods such as quizzes. Influencing factors of an EBN culture were: (a) support of managers, (b) inspiring facilitators close to the team, and (c) stable teams with driving forces and student nurses. Conclusions: Integrating EBN into daily practice in creative and motivating ways contributes to the development of an EBN culture in nursing homes. To facilitate this, managers should support teams in the process and content of EBN, and internal facilitators should collaborate with driving forces on the teams.

Beliefs and implementation of evidence-based practice among nurses in the nursing homes of a Swiss canton: An observational cross-sectional study

Aims and objectives

Examine beliefs about EBP and its level of implementation among nurses working in nursing homes in a bilingual canton of Switzerland and explore associations between these aspects and nurses’ sociodemographic and professional characteristics.

Background

Although evidence‐based practice (EBP) is recognised as an effective strategy for improving the quality and safety of care, little is known about its use in nursing homes. Nurses’ beliefs about EBP and their implementation of it in Switzerland’s nursing homes have never been explored.

Design

An observational cross‐sectional study.

Methods

Beliefs about and implementation of EBP were evaluated using validated French‐ and German‐language versions of the EBP Beliefs Scale and the EBP Implementation Scale, developed by Melnyk and Fineout‐Overholt (Melnyk, Fineout‐Overholt, & Mays, 2008, Worldviews on Evidence‐Based Nursing, 5, 208). The STROBE checklist for cross‐sectional studies was used in reporting this study.

Results

The participation rate was 40.6% (N = 194). Most participants stated that they had some knowledge of EBP and held favourable beliefs about it. Nevertheless, 37.1% of participants found the concept complicated and 36.1% found it time‐consuming. Participants were more likely to implement stages in the EBP process linked to direct clinical practice rather than those which required scientific knowledge and skills.

Conclusion

Most participants had favourable beliefs about EBP, but the level of implementation of EBP among nurses in their daily clinical practice was sub‐optimal.

Relevance to clinical practice

A greater emphasis should be put on fostering the use of EBP among nurses working in nursing homes. This could be achieved via training and the development of individual, institutional and contextual strategies promoting the integration of EBP in clinical settings.

Implementing practices focused on workplace health and psychological wellbeing: A systematic review

RATIONALE

Workplace health and wellbeing practices (WHWPs) often fail to improve psychological health or wellbeing because of implementation failure. Thus, implementation should be evaluated to improve the effectiveness of WHWPs.

OBJECTIVE

We conducted a systematic review to identify critical success factors for WHWP implementation and gaps in the evidence. Doing so provides a platform for future theoretical development.

METHODS

We reviewed 74 separate studies that assessed the implementation of WHWPs and their effects on psychological health or psychological wellbeing. Most studies were from advanced industrial Western democracies (71). Intervention types included primary (e.g., work redesign, 37 studies; and health behavior change, 8 studies), secondary (e.g., mindfulness training, 11 studies), tertiary (e.g., focused on rehabilitation, 9 studies), and multifocal (e.g., including components of primary and secondary, 9 studies).

RESULTS

Tangible changes preceded improvements in health and wellbeing, indicating intervention success cannot be attributed to non-specific factors. Some interventions had beneficial effects through mechanisms not planned as part of the intervention. Three factors were associated with successful WHWP implementation: continuation, learning, and effective governance.

CONCLUSIONS

The review indicates future research could focus on how organizations manage conflict between WHWP implementation and existing organizational processes, and the dynamic nature of organizational contexts that affect and are affected by WHWP implementation. This systematic review is registered [PROSPERO: the International Prospective Register of Systematic Reviews ID: CRD42019119656].

Exploring the role of external experts in supporting staff to implement psychosocial interventions in care home settings: results from the process evaluation of a randomized controlled trial

BACKGROUND

Psychosocial interventions offer opportunities to improve care for people with dementia in care homes. However, implementation is often led by staff who are not well prepared for the role. Some interventions use external experts to support staff. However little is known about external expert, care home staff and manager perceptions of such support. This paper addresses this gap.

METHODS

Multi-methods study within a process evaluation of a cluster randomised controlled trial of Dementia Care Mapping™ (DCM). Interviews were conducted with six external experts who also completed questionnaires, 17 care home managers and 25 care home staff responsible for DCM implementation. Data were analysed using descriptive statistics and template analysis.

RESULTS

Three themes were identified: the need for expert support, practicalities of support and broader impacts of providing support. Expert support was vital for successful DCM implementation, although the five-days provided was felt to be insufficient. Some homes felt the support was inflexible and did not consider their individual needs. Practical challenges of experts being located at a geographical distance from the care homes, limited when and how support was available. Experts gained knowledge they were able to then apply in delivering DCM training. Experts were not able to accurately predict which homes would be able to implement DCM independently in future cycles.

CONCLUSIONS

An external expert may form a key component of successful implementation of psychosocial interventions in care home settings. Future research should explore optimal use of the expert role.

A collective case study of the features of impactful dementia training for care home staff

Background

Up to 80% of care home residents have dementia. Ensuring this workforce is appropriately trained is of international concern. Research indicates variable impact of training on a range of resident and staff outcomes. Little is still known about the most effective approaches to the design, delivery and implementation of dementia training. This study aimed to investigate the features and contextual factors associated with an effective approach to care home staff training on dementia.

Methods

An embedded, collective case study was undertaken in three care home provider organisations who had responded to a national training audit. Data collected included individual or small group interviews with training leads, facilitators, staff attending training, managers, residents and their relatives. Observations of care practice were undertaken using Dementia Care Mapping. Training delivery was observed and training materials audited. A within case analysis of each site, followed by cross case analysis using convergence coding was undertaken.

Results

All sites provided bespoke, tailored training, delivered largely using face-to-face, interactive methods, which staff and managers indicated were valuable and effective. Self-study booklets and on-line learning where were used, were poorly completed and disliked by staff. Training was said to improve empathy, knowledge about the lived experience of dementia and the importance of considering and meeting individual needs. Opportunities to continually reflect on learning and support to implement training in practice were valued and felt to be an essential component of good training. Practice developments as a result of training included improved communication, increased activity, less task-focussed care and increased resident well-being. However, observations indicated positive well-being and engagement was not a consistent experience across all residents in all sites. Barriers to training attendance and implementation were staff time, lack of dedicated training space and challenges in gaining feedback on training and its impact. Facilitators included a supportive organisational ethos and skilled training facilitation.

Conclusions

Effective training is tailored to learners’, delivered face-to-face by an experienced facilitator, is interactive and is embedded within a supportive organisational culture/ethos. Further research is needed on the practical aspects of sustainable and impactful dementia training delivery and implementation in care home settings.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1186-z) contains supplementary material, which is available to authorized users.