Implementing an intervention to reduce use of antibiotics for suspected urinary tract infection in nursing homes - a qualitative study of barriers and enablers based on Normalization Process Theory

Detection and management of suspected infections in people with dementia - A scoping review of current practices

People with dementia have an increased risk of hospitalization and mortality due to infections. We aimed to explore decision-making processes and interventions for detecting and managing suspected infections in people with dementia and involved actors and determinants. We conducted a scoping review, searching CINAHL and PubMed, and synthesized data through mapping and narratively. We identified 22 studies, based mostly on nursing homes and US data. Decision-making processes included recognition of infections based on observations of early signs and symptoms, actions when suspecting infections, and proxy/family involvement. Interventions included antimicrobial stewardship and other decision-support tools. Determinants included healthcare staff perceptions, and other system/person-related factors. Healthcare staff were the main actors, proxy/family were mentioned scarcely, and people with dementia only once. Our findings show scarcity of evidence on people with dementia and outside of the nursing homes. We highlight knowledge gaps and inform research shaping interventions for improving infection detection and management.

Leading the way: implementing aged care innovations

OBJECTIVES

The objective of this study was to identify the key characteristics of leaders that support the implementation of innovations in aged care settings.

METHODS

We conducted a secondary analysis of papers from a large scoping review that identified how leaders supported the implementation of innovations in aged care. Once imported into NVivo12, the findings were deductively coded using the domains of Bloom's taxonomy of learning. Each parent code was then inductively analyzed to identify key characteristics within each domain.

RESULTS

Our review identified four types of knowledge, five skills, and six attitudes that leaders should exhibit to better support the implementation of innovations within aged care settings. In addition to our findings regarding Bloom's learning domains, we identified nine leadership behaviors that participants in the included papers perceived as valuable for enhancing the implementation process. Furthermore, we identified four key organizational elements that support leaders in navigating and facilitating the implementation of innovations within aged care settings.

CONCLUSION

Our review identified the characteristics that leaders should demonstrate when supporting the implementation of innovations in aged care. Importantly, our findings also emphasized the changing role of leadership from a hierarchical approach to a more collaborative, supportive, and empowering style. The insights identified in this review will help to guide aged care leaders, stressing the significance of adaptable and relational leadership styles that will guide the implementation of innovations within the aged care sector.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A271.

Fostering an aged care organizational culture that supports innovation

AIM

This study aimed to identify how aged care organizations can foster a culture that supports the implementation of innovation.

INTRODUCTION

The aged care sector must innovate to meet clients' evolving needs and increased regulatory requirements. Given the need to account for the values, beliefs, expectations, and assumptions held by a diverse range of stakeholders, implementing innovations within aged care can be exceptionally complex. Fostering a supportive organizational culture can facilitate the implementation of these critical innovations.

METHODS

Papers from a large scoping review that identified organizational culture as a barrier and/or enabler to implementing innovations in aged care were imported into NVivo. Data relating to how organizations fostered (or could foster) a culture that supported the implementation of innovations were then extracted, inductively coded, interpreted, and grouped into approaches.

RESULTS

Of the 193 papers from the original scoping review, 109 were included in this secondary analysis. From these 109 papers, we identified six key approaches: cultivating collaboration; valuing contributions; ensuring alignment between the organizational vision, culture, and innovation; demonstrating organizational commitment; developing and communicating the implementation plan; and accounting for stability.

CONCLUSIONS

Our study outlines effective approaches that can be used by aged care organizations to cultivate a culture that supports the implementation of innovations. However, these approaches should not be viewed in isolation; rather, they are interconnected and mutually reinforcing. Together, these insights offer practical guidance for aged care entities seeking to adapt and evolve through innovation implementation.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A264.

Preventing urinary tract infection in older people living in care homes: the 'StOP UTI' realist synthesis

BACKGROUND

Urinary tract infection (UTI) is the most diagnosed infection in older people living in care homes.

OBJECTIVE

To identify interventions for recognising and preventing UTI in older people living in care homes in the UK and explain the mechanisms by which they work, for whom and under what circumstances.

METHODS

A realist synthesis of evidence was undertaken to develop programme theory underlying strategies to recognise and prevent UTI. A generic topic-based search of bibliographic databases was completed with further purposive searches to test and refine the programme theory in consultation with stakeholders.

RESULTS

56 articles were included in the review. Nine context-mechanism-outcome configurations were developed and arranged across three theory areas: (1) Strategies to support accurate recognition of UTI, (2) care strategies for residents to prevent UTI and (3) making best practice happen. Our programme theory explains how care staff can be enabled to recognise and prevent UTI when this is incorporated into care routines and activities that meet the fundamental care needs and preferences of residents. This is facilitated through active and visible leadership by care home managers and education that is contextualised to the work and role of care staff.

CONCLUSIONS

Care home staff have a vital role in preventing and recognising UTI in care home residents.Incorporating this into the fundamental care they provide can help them to adopt a proactive approach to preventing infection and avoiding unnecessary antibiotic use. This requires a context of care with a culture of personalisation and safety, promoted by commissioners, regulators and providers, where leadership and resources are committed to support preventative action by knowledgeable care staff.

Nursing home nurses' opinions on the potential evolution of their role in antibiotic stewardship: A French national cross-sectional survey

AIMS

To assess French nursing home nurses' opinions on the potential evolution of their antibiotic stewardship role, facilitators and barriers, and nurses' characteristics associated with their opinion toward new roles regarding antibiotic prescribing.

DESIGN

We conducted a cross-sectional study in French nursing homes with ≥20 beds and for which an email address was available in a national database managed by the French government between May and June 2022.

METHODS

A self-administered internet-based questionnaire of 43 closed-ended Likert items was sent to directors of eligible nursing homes by email asking them to forward the link to the questionnaire to the nurses and head nurses of their institution. Data analysis included descriptive statistics and χ2 tests.

RESULTS

7215 nursing homes were sent the online questionnaire; 1090 participants completed it partially or totally and 923 fully filled in the questionnaire. A majority of nurses supported strengthening and expanding their antibiotic stewardship role. Regarding new roles, over 70% agreed that nurses could collect urine samples to perform a urine culture on their own initiative, prescribe microbiological laboratory tests, and change the drug formulation or the administration route of the antibiotic prescribed by the general practitioner. One-third declared that they could initiate antibiotics for some infections and/or change the empirical antibiotic treatment prescribed by the general practitioner. Nurses from public nursing homes with connection to a hospital (27.5% vs. >35% for other status) and with recent experience in nursing homes (31% for <5 years of practice vs. 41% for 10 years or more) were less likely to agree to prescribe antibiotics.

CONCLUSIONS

This quantitative questionnaire survey identified potential new nurses' roles in antibiotic stewardship that seem to be acceptable and feasible for participants. These new nurses' roles need to be explored in future experimentations before considering implementation.

REPORTING METHOD

The study adhered to relevant EQUATOR guidelines and followed the STROBE reporting guidelines.

PATIENT OR PUBLIC CONTRIBUTION

A self-administered internet-based questionnaire was sent to directors of eligible nursing homes by email asking them to forward the link to the questionnaire to the nurses and head nurses of their institution. Nurses and head nurses who were interested and willing could complete the questionnaire online partially or fully.

TRIAL AND PROTOCOL REGISTRATION

This study is not a clinical trial and is not eligible for trial registration. We used another suitable study registration site, the Center for Open Science.

Assessment of implementation strategies adopted for antimicrobial stewardship interventions in long-term care facilities: a systematic review

BACKGROUND

The implementation of antimicrobial stewardship (AMS) interventions in long-term care facilities (LTCFs) is influenced by multi-level factors (resident, organizational, and external) making their effectiveness sensitive to the implementation context.

OBJECTIVES

This study assessed the strategies adopted for the implementation of AMS interventions in LTCFs, whether they considered organizational characteristics, and their effectiveness.

DATA SOURCES

Electronic databases until April 2022.

STUDY ELIGIBILITY CRITERIA

Articles covering implementation of AMS interventions in LTCFs.

ASSESSMENT OF RISK OF BIAS

Mixed Methods Appraisal Tool for empirical studies.

METHODS OF DATA SYNTHESIS

Data were collected on AMS interventions and context characteristics (e.g. type of facility, staffing, and residents). Implementation strategies and outcomes were mapped according to the Expert Recommendations for Implementing Change (ERIC) framework and validated taxonomy for implementation outcomes. Implementation and clinical effectiveness were assessed according to the primary and secondary outcomes results provided in each study.

RESULTS

Among 48 studies included in the analysis, 19 (40%) used implementation strategies corresponding to one to three ERIC domains, including education and training (n = 36/48, 75%), evaluative and iterative strategies (n = 24/48, 50%), and support clinicians (n = 23/48, 48%). Only 8/48 (17%) studies made use of implementation theories, frameworks, or models. Fidelity and sustainability were reported respectively in 21 (70%) and 3 (10%) of 27 studies providing implementation outcomes. Implementation strategy was considered effective in 11/27 (41%) studies, mainly including actions to improve use (n = 6/11, 54%) and education (n = 4/11, 36%). Of the 42 interventions, 18/42 (43%) were deemed clinically effective. Among 21 clinically effective studies, implementation was deemed effective in four and partially effective in five. Two studies were clinically effective despite having non-effective implementation.

CONCLUSIONS

The effectiveness of AMS interventions in LTCFs largely differed according to the interventions' content and implementation strategies adopted. Implementation frameworks should be considered to adapt and tailor interventions and strategies to the local context.

Rethinking Barriers and Enablers in Qualitative Health Research: Limitations, Alternatives, and Enhancements

Explorations of barriers and enablers (or barriers and facilitators) to a desired health practice, implementation process, or intervention outcome have become so prevalent that they seem to be a default in much health services and public health research. In this article, we argue that decisions to frame research questions or analyses using barriers and enablers (B&Es) should not be default. Contrary to the strengths of qualitative research, the B&Es approach often bypasses critical reflexivity and can lead to shallow research findings with poor understanding of the phenomena of interest. The B&Es approach is untheorised, relying on assumptions of linear, unidirectional processes, universally desirable outcomes, and binary thinking which are at odds with the rich understanding of context and complexity needed to respond to the challenges faced by health services and public health. We encourage researchers to develop research questions using informed deliberation that considers a range of approaches and their implications for producing meaningful knowledge. Alternatives and enhancements to the B&Es approach are explored, including using 'whole package' methodologies; theories, conceptual frameworks, and sensitising ideas; and participatory methods. We also consider ways of advancing existing research on B&Es rather than doing 'more of the same': researchers can usefully investigate how a barrier or enabler works in depth; develop and test implementation strategies for addressing B&Es; or synthesise the B&Es literature to develop a new model or theory. Illustrative examples from the literature are provided. We invite further discussion on this topic.

Implementation of an intervention to reduce urine dipstick testing in aged care homes: a qualitative study of enablers and barriers, and strategies to enhance delivery

OBJECTIVE

The 'To Dip or Not to Dip' (TDONTD) intervention aims to reduce antibiotic prescribing for urinary tract infection (UTI) by reducing low-value dipstick testing. The aims of this study were to use a qualitative approach to (1) evaluate potential influences on the delivery of the TDONTD intervention in Australian residential aged care homes (RACHs) by identifying perceived barriers and enablers to delivery and acceptance; and (2) propose intervention strategies to address barriers and enhance enablers.

DESIGN

A qualitative before-after process evaluation of a multisite implementation study using interviews with nurse and pharmacist implementers.

SETTING

This study was conducted in 12 Australian RACHs.

PARTICIPANTS

Participants included 17 on-site nurse champions and 4 pharmacists (existing contracted providers).

INTERVENTION

Resources from England's TDONTD intervention were adapted for an Australian context. Key resources delivered were case-based education, staff training video, clinical pathway and an audit tool.

RESULTS

Key barriers to TDONTD were beliefs about nursing capabilities in diagnosing infection, beliefs about consequences (fear of missing infection) and social influences (pressure from family, doctors and hospitals). Key enablers were perceived increased nurse and carer knowledge (around UTI and asymptomatic bacteriuria), resources from a credible source, empowerment of nurse champions to apply knowledge and skills in delivering operational change initiatives, pharmacist-delivered education and organisational policy or process change. Of TDONTD's key components, the clinical pathway substituted dipstick testing in diagnosing UTI, delivery of case-based education was enhanced by their attendance and support of the intervention and the antibiotic audit tool generated feedback that champions shared with staff.

CONCLUSIONS

Our study confirms the core components of TDONTD and strategies to enhance delivery and overcome barriers. To further reduce barriers to TDONTD, broader advocacy work is required to raise awareness of dipstick testing as a low-value test in older persons and by linking it to healthcare professionals and consumer education.

Study of Whole blood in Frontline Trauma (SWiFT): implementation study protocol

INTRODUCTION

Uncontrolled bleeding is a major cause of death for patients with major trauma. Current transfusion practices vary, and there is uncertainty about the optimal strategy. Whole blood (WB) transfusion, which contains all components in one bag, is considered potentially advantageous, particularly for resuscitating patients with major bleeding in the prehospital setting. It could potentially improve survival, reduce donor risk and simplify the processes of delivering blood transfusions outside hospitals. However, the evidence supporting the effectiveness and safety of WB compared with the standard separate blood component therapy is limited. A multicentre randomised controlled trial will be conducted, alongside an implementation study, to assess the efficacy, cost-effectiveness and implementation of prehospital WB transfusion in the prehospital environment. The implementation study will focus on evaluating the acceptability and integration of the intervention into clinical settings and on addressing broader contextual factors that may influence its success or failure.

METHODS AND ANALYSIS

A type 1 effectiveness-implementation hybrid design will be employed. The implementation study will use qualitative methods, encompassing comprehensive interviews and focus groups with operational staff, patients and blood donor representatives. Staff will be purposefully selected to ensure a wide range of perspectives based on their professional background and involvement in the WB pathway. The study design includes: (1) initial assessment of current practice and processes in the WB pathway; (2) qualitative interviews with up to 40 operational staff and (3) five focus groups with staff and donor representatives. Data analysis will be guided by the theoretical lenses of the Normalisation Process Theory and the Theoretical Framework of Acceptability.

ETHICS AND DISSEMINATION

The study was prospectively registered and approved by the South Central-Oxford C Research Ethics Committee and the Health Research Authority and Health and Care Research Wales. The results will be published in peer-reviewed journals and provided to all relevant stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072.

Factors that influence the implementation of innovation in aged care: a scoping review

OBJECTIVE

The objective of this scoping review is to identify factors that influence the implementation of innovation in aged care.

INTRODUCTION

Aged care is a dynamic sector experiencing rapid change. Implementation of innovations in aged care has received relatively little research attention compared to health care.

INCLUSION CRITERIA

This review included studies of any design, that examined the implementation of innovations in aged care settings.

METHODS

Searches were conducted in MEDLINE, CINAHL, AgeLine, and ProQuest Social Sciences Premium Collection for studies published between January 1, 2012 and December 31, 2022. The titles and abstracts of retrieved citations were screened by two independent reviewers. Full-text articles were screened by one reviewer to determine inclusion. Data were extracted in NVivo using a tool developed by the research team. Factors that influenced implementation were inductively coded, interpreted, and grouped into categories in a series of workshops.

RESULTS

Of the 2530 studies that were screened, 193 were included. Of the included papers, the majority (74%) related to residential aged care, 28% used an implementation theory or framework, and 15% involved consumers. Five key categories of factors influencing implementation were identified: organizational context including resourcing and culture; people's attitudes and capabilities; relationships between people; the intervention and its appropriateness; and implementation actions such as stakeholder engagement and implementation strategies.

CONCLUSIONS

Our findings can be used to develop practical resources to support implementation efforts, and highlight the importance of resourcing for successful implementation. Attention to community-based aged care, and greater engagement with theory and community is needed to promote research rigor, relevance and applicability.

Healthcare and community stakeholders' perceptions of barriers and facilitators to implementing a behavioral activation intervention for people with dementia and depression: a qualitative study using Normalization Process Theory

BACKGROUND

Depression is commonly experienced by people with dementia, and associated with lower quality of life and functional decline. However, access to evidence-based psychological interventions for people with dementia and depression is limited. One potential solution is guided low-intensity behavioral activation. Following the new Medical Research Council Framework, considering factors such as potential barriers and facilitators to implementation is recommended during the development of new interventions. Aims of this study were to: (1) develop an understanding of existing healthcare and community support in the Swedish context for people with dementia and their informal caregivers; and (2) identify barriers and facilitators to intervention uptake informed by Normalization Process Theory.

METHODS

Semi-structured interviews and focus groups were held with healthcare (n = 18) and community (n = 7) stakeholders working with people with dementia and/or informal caregivers. Interview questions were informed by Normalization Process Theory. Data was analysed utilizing a two-step deductive analysis approach using the Normalization Process Theory coding manual, with inductive categories applied to data related to the main mechanisms of the theory, but not captured by its sub-constructs.

RESULTS

Twelve deductive and three inductive categories related to three Normalization Process Theory primary mechanisms (Coherence, Cognitive Participation, and Collective Action) were identified. Identified barriers to intervention uptake included: (1) additional burden for informal caregivers; (2) lack of appropriate workforce to provide guidance; (3) lack of time and financial resources; (4) people with dementia not recognising their diagnosis of dementia and/or a need for support; and (5) stigma. Identified facilitators to intervention uptake included: (1) intervention has potential to fill a large psychological treatment gap in Sweden; (2) objectives and potential benefits understood and agreed by most stakeholders; and (3) some healthcare professionals recognized their potential role in providing intervention guidance.

CONCLUSIONS

Several barriers and facilitators for future implementation, specific to the intervention, individuals and families, as well as professionals, were identified during intervention development. Barriers were mapped into evidence-based implementation strategies, which will be adopted to overcome identified barriers. A feasibility study further examining implementation potential, acceptability and feasibility, alongside clinical, methodological, and procedural uncertainties associated with the intervention will be conducted.

TRIAL REGISTRATION

Not applicable.

Identifying barriers and enablers to participation in infection surveillance in Australian residential aged care facilities

BACKGROUND

Infection surveillance is a vital part of infection prevention and control activities for the aged care sector. In Australia there are two currently available infection and antimicrobial use surveillance programs for residential aged care facilities. These programs are not mandated nor available to all facilities. Development of a new surveillance program will provide standardised surveillance for all facilities in Australia.

METHODS

This study aimed to assess barriers and enablers to participation in the two existing infection and antimicrobial use surveillance programs, to improve development and implementation of a new program. A mixed-methods study was performed. Aged Care staff involved in infection surveillance were invited to participate in focus groups and complete an online survey comprising 17 items. Interviews were transcribed and analysed using the COM-B framework.

RESULTS

Twenty-nine staff took part in the focus groups and two hundred took part in the survey. Barriers to participating in aged care infection surveillance programs were the time needed to collect and enter data, competing priority tasks, limited understanding of surveillance from some staff, difficulty engaging clinicians, and staff fatigue after the COVID-19 pandemic. Factors that enabled participation were previous experience with surveillance, and sharing responsibilities, educational materials and using data for benchmarking and to improve practice.

CONCLUSION

Streamlined and simple data entry methods will reduce the burden of surveillance on staff. Education materials will be vital for the implementation of a new surveillance program. These materials must be tailored to different aged care workers, specific to the aged care context and provide guidance on how to use surveillance results to improve practice.

Supporting translation of research evidence into practice-the use of Normalisation Process Theory to assess and inform implementation within randomised controlled trials: a systematic review

BACKGROUND

The status of randomised controlled trials (RCTs) as the 'gold standard' for evaluating efficacy in healthcare interventions is increasingly debated among the research community, due to often insufficient consideration for implementation. Normalisation Process Theory (NPT), which focuses on the work required to embed processes into practice, offers a potentially useful framework for addressing these concerns. While the theory has been deployed in numerous RCTs to date, more work is needed to consolidate understanding of if, and how, NPT may aid implementation planning and processes within RCTs. Therefore, this review seeks to understand how NPT contributes to understanding the dynamics of implementation processes within RCTs. Specifically, this review will identify and characterise NPT operationalisation, benefits and reported challenges and limitations in RCTs.

METHODS

A qualitative systematic review with narrative synthesis of peer-reviewed journal articles from eight databases was conducted. Studies were eligible for inclusion if they reported sufficient detail on the use of NPT within RCTs in a healthcare domain. A pre-specified data extraction template was developed based on the research questions of this review. A narrative synthesis was performed to identify recurrent findings.

RESULTS

Searches identified 48 articles reporting 42 studies eligible for inclusion. Findings suggest that NPT is primarily operationalised prospectively during the data collection stage, with limited sub-construct utilisation overall. NPT is beneficial in understanding implementation processes by aiding the identification and analysis of key factors, such as understanding intervention fidelity in real-world settings. Nearly three-quarters of studies failed to report the challenges and limitations of utilising NPT, though coding difficulties and data falling outside the NPT framework are most common.

CONCLUSIONS

NPT appears to be a consistent and generalisable framework for explaining the dynamics of implementation processes within RCTs. However, operationalisation of the theory to its full extent is necessary to improve its use in practice, as it is currently deployed in varying capacities. Recommendations for future research include investigation of NPT alongside other frameworks, as well as earlier operationalisation and greater use of NPT sub-constructs.

TRIAL REGISTRATION

The protocol for this systematic review was accepted for public registration on PROSPERO (registration number: CRD42022345427) on 26 July 2022.

Feasibility of a placebo-controlled trial of antibiotics for possible urinary tract infection in care homes: a qualitative interview study

BACKGROUND

Diagnosis of suspected urinary tract infection (UTI) in care and nursing home residents is commonly based on vague non-localising symptoms (for example, confusion), potentially leading to inappropriate antibiotic prescription. The safety of withholding antibiotics in such cases could be addressed by a randomised controlled trial (RCT); however, this would require close monitoring of residents, and support from care home staff, clinicians, residents, and families.

AIM

To explore the views of residential care and nursing home staff (herein referred to as care home staff) and primary care clinicians on the feasibility and design of a potential RCT of antibiotics for suspected UTI in care home residents, with no localising urinary symptoms.

DESIGN & SETTING

A qualitative interview study with primary care clinicians and care home staff in the UK.

METHOD

Semi-structured interviews with 16 care home staff and 11 primary care clinicians were thematically analysed.

RESULTS

Participants were broadly supportive of the proposed RCT. The safety of residents was a priority and there was strong support for using the RESTORE2 (Recognise Early Soft Signs, Take Observations, Respond, Escalate) assessment tool to monitor residents; however, there were concerns about associated training requirements, especially for night and temporary staff. Effective communication (with residents, families, and staff) was deemed essential, and carers were confident that residents and families would be supportive of the RCT if the rationale was clearly explained and safety systems were robust. There were mixed views on a placebo-controlled design. The perceived additional burden was seen as a potential barrier, and the use of temporary staff and the out-of-hours period were highlighted as potential risk areas.

CONCLUSION

The support for this potential trial was encouraging. Future development will need to prioritise resident safety (especially in the out-of-hours period), effective communication, and minimising additional burden on staff to optimise recruitment.