Implementation of evidence-based guidance for dementia palliative care using participatory action research: examining implementation through the Consolidated Framework for Implementation Research (CFIR)

Adapting Dementia Care Management to a Regional German Context: Assessment of Changes in Acceptability, Appropriateness, and Feasibility

Dementia care management, an evidence-based care concept in Germany, optimizes care for people with dementia and their caregivers. Implemented by qualified professionals, it comprises intervention modules addressing treatment and care, medication management, and caregiver support. Positively evaluated in one federal state, it's recommended for nationwide integration into routine care. Since the infrastructure of the German healthcare system differs regionally, the concept underwent adaption for regional implementation in a participatory, iterative process. Five local healthcare experts as co-researchers tested and adjusted selected components of the concept in a pilot study. This trend analysis aims to assess the adapted concept for acceptance, appropriateness, and feasibility. A total of 89 intervention modules were tested over 18 weeks, and the co-researcher's assessment was gathered through an accompanying online survey. The participatory process itself was rated positively overall, but technical problems had a negative impact on the implementation and evaluation of the care concept.

Pain Management Education for Rural Hospice Family Caregivers: A Pilot Study With Embedded Implementation Evaluation

BACKGROUND

Assessing and managing hospice patients' pain is a common source of anxiety among hospice family caregivers (HFCGs), especially caregivers in rural communities who face special challenges including distance, limited access, and concerns about opioid misuse.

OBJECTIVE

To pilot test Ready2Care, a pain management education intervention for rural HFCGs. We sought to determine whether there was a signal of benefit for clinically-relevant outcomes and to identify contextual factors pertinent to conducting a future randomized clinical trial of Ready2Care.

METHODS

We conducted a multi-method, single-arm study, enabling completion of paired t-tests comparing pre- and post-intervention measures of caregiver anxiety, pain management self-efficacy, barriers to pain management, and reports of patient pain intensity and corresponding patient and caregiver distress. We concurrently conducted an embedded implementation evaluation via calculation of descriptive statistics (recruitment and retention data) and directed content analysis of brief caregiver interviews.

RESULTS

Twenty-seven (n = 27) HFCGs participated; 15 completed the study. Among completers, significant improvement was observed in patient pain intensity (average 1.4 points decrease on 0-10 scale) and in overall pain experience. No statistically significant changes were detected in caregiver anxiety, barriers to pain management, or pain management self-efficacy. Facilitators to successful conduct of a future clinical trial included high acceptability of Ready2Care, driven by its perceived clarity and relevance to caregivers' concerns. Barriers included lower-than-anticipated accrual and an attrition rate of nearly 44%.

CONCLUSION

A multisite clinical trial of Ready2Care is warranted; however, its success may require more effective recruitment and retention strategies for rural caregiver participants.

Development and validation of clinical implementation methods for patient-reported outcomes in Japanese multi-center palliative care units

BACKGROUND

Patient-Reported Outcomes (PROs) are recommended for use in clinical oncology. However, they are not routinely used in professional palliative care practices in Japan. The reasons include both patient and healthcare provider factors and the implementation of PROs. This study aimed to develop and validate clinical implementation methods for PROs in Japanese palliative care units.

METHODS

The Consolidated Framework for Implementation Research (CFIR) was conducted with four palliative care units in Japan. The study was conducted in six steps: unit assessment, development and implementation of a PRO implementation plan, PRO post-implementation survey and analysis of its utilization, a review of the PRO implementation process, creation of a PRO implementation method in a palliative care unit, and use and verification of the implementation method. Steps 1-5 were the development phase, and step 6 was the verification phase.

RESULTS

Interviews were conducted with healthcare providers prior to PRO implementation. Intervention characteristics, patient needs in the palliative care unit, and factors related to the organization were identified as barriers. The implementation plan was developed, and the core members were selected. The implementation procedures were created in the above mentioned steps. PROs were used in the palliative care units. The same was true in the validation phase.

CONCLUSIONS

This study guided PROs in specialized palliative care unit in a clinical setting. The method was developed and validated for the implementation of PROs in the palliative care unit. In the PRO implementation process, it was important to assess the unit, address the barriers to implementation, and reduce the burden on healthcare providers. Furthermore, healthcare providers had to be supported by the champion, a person responsible for the implementation of PROs in the palliative care unit.

Ready or Not: A Conceptual Model of Organizational Readiness for Embedded Pragmatic Dementia Research

The National Institute on Aging Alzheimer's Disease/Alzheimer's Disease and Related Dementias Research Implementation Milestones emphasize the need for implementation research that maximizes up-take and scale-up of evidence-based dementia care practices across settings, diverse populations, and disease trajectories. Organizational readiness for implementation is a salient consideration when planning and conducting embedded pragmatic trials, in which interventions are implemented by provider staff. The current article examines the conceptual and theoretical underpinnings of organizational readiness for implementation and the operationalization of this construct. We offer a preliminary conceptual model for explicating and measuring organizational readiness and describe the unique characteristics and demands of implementing evidence-based interventions targeting persons with dementia and/or their care partners. [Research in Gerontological Nursing, 17(3), 149-160.].

Implementing a new living concept for persons with dementia in long-term care: evaluation of a quality improvement process

BACKGROUND

Improving quality of nursing home care for residents is a constant focus of stakeholders involved within quality improvement projects. Though, achieving change in long-term care is challenging. Process evaluations provide insight into the nature, exposure and experiences of stakeholders and influencing mechanisms for implementation. The aim of this study is to gain insight into the process and facilitating and hindering mechanisms of implementing a quality improvement project that seeks to create a dementia-friendly community with a nursing home at its core.

METHODS

For the process evaluation we planned a case study design with an ethnographic approach. Various research methods were used: qualitative observations, focus groups, interviews and questionnaires for various stakeholders and document review. Data collection and analyses in this study is based on the Consolidated Framework for Implementation Research.

RESULTS

Four main lessons were learned. Firstly, nursing staff are crucial to achieve more freedom for residents. Secondly, high-impact changes in daily care need strong and sustainable focus from the care organisation. Thirdly, dementia-friendly societies should be deployed from multiple actors, which entails long-term collaborations with external stakeholders. Fourthly, the transition to a dementia-friendly society requires meeting spaces for and a focus on both residents and people from the community. Consequently, local residents are shifting from external to internal stakeholders, extending beyond the regular involvement of informal carers and volunteers within the nursing home.

CONCLUSIONS

Nursing homes are part of the local community and provide opportunities to collaborate on a dementia-friendly society. However, the change that is required (promoting freedom, residents' autonomy and the redesign of care processes) is complex and influenced by various mechanisms. Understanding these mechanisms can benefit other care organisations that strive to implement a similar initiative.

A Process Evaluation of an Antibiotic Stewardship Intervention for Urinary Tract Infections in Nursing Homes

OBJECTIVES

To assess the internal and external validity of a cluster randomized controlled trial (cRCT) evaluating a decision tool with supportive interventions for the empirical treatment of urinary tract infections (UTIs) in nursing homes (NHs), and to identify facilitators and barriers in implementing this antibiotic stewardship intervention.

DESIGN

Mixed-methods process evaluation study.

SETTING AND PARTICIPANTS

Physicians, nursing staff, client council members, and residents of Dutch NHs.

METHODS

We used cRCT data of the ANNA study (Antibiotic Prescribing and Non-prescribing in Nursing Home Residents With Signs and Symptoms Ascribed to Urinary Tract Infection). In addition, we sent out an online evaluation questionnaire, conducted semistructured interviews with physicians and nursing staff, and consulted client council members.

RESULTS

Internal validity was lowered: control group physicians participated in several non-study-related activities regarding UTI. External validity was good: almost all intervention components had a high fidelity (52%-74%) and were perceived as relevant (physicians: 7.2-8.6 of 10, nursing staff: 6.5-8.5 of 10) and feasible (physicians: 7.5 of 10, nursing staff 6.4 of 10), with feasibility for residents with dementia and urine incontinence needing attention. The most common reason for deviating from the advice generated by the decision tool was an unclear illness presentation. Identified facilitators to implementation were confidence in the intervention, repeated intervention encounter, and having "champions" in the NH. Barriers were limited involvement of nursing staff, unstable nursing teams, residents' and representatives' belief that antibiotics should be prescribed, and a low antibiotic prescribing threshold within the NH culture.

CONCLUSIONS AND IMPLICATIONS

Lowered internal validity may have reduced the study effect. Attention should be paid to the feasibility of the intervention in residents with dementia and urinary incontinence. Improvement opportunities for implementation were higher nursing staff involvement and repeated intervention offering.

"Currently flying blind" Stakeholders' perceptions of implementing statewide population-based cancer staging at diagnosis into the Western Australian Cancer Registry: a rapid qualitative process evaluation of the WA Cancer Staging Project

BACKGROUND

Cancer stage at diagnosis is essential for understanding cancer outcomes, guiding cancer control activities and healthcare services, and enabling benchmarking nationally and internationally. Yet, most cancer registries in Australia do not routinely collect this data. This study explored key stakeholders' perceptions of implementing cancer staging utilising Natural Language Processing and Machine Learning algorithms within the Western Australian Cancer Registry.

METHODS

Perceptions of key breast and colorectal cancer stakeholders, including registry staff, clinicians, consumers, data scientists, biostatisticians, data management, healthcare staff, and health researchers, were collected. Prospective and retrospective qualitative proformas at two-time points of the Western Australian Cancer Staging Project were employed. The Consolidated Framework for Implementation Research was used to guide data collection, analysis and interpretation embedded in a Participatory Action Research approach. Data analysis also incorporated Framework Analysis and an adapted version of grading qualitative data using a visual traffic light labelling system to highlight the levels of positivity, negativity, and implementation concern.

RESULTS

Twenty-nine pre-proformas and 18 post-proformas were completed online via REDCap. The grading and visual presentation of barriers and enablers aided interpretation and reviewing predicted intervention outcomes. Of the selected constructs, complexity (the perceived difficulty of the intervention) was the strongest barrier and tension for change (the situation needing change) was the strongest enabler. Implementing cancer staging into the Western Australian Cancer Registry was considered vital. Benefits included improved knowledge and understanding of various outcomes (e.g., treatment received as per Optimum Care Pathways) and benchmarking. Barriers included compatibility issues with current systems/workflows, departmental/higher managerial support, and future sustainment.

CONCLUSIONS

The findings aid further review of data gaps, additional cancer streams, standardising cancer staging and future improvements. The study offers an adapted version of a rapid qualitative data collection and analytic approach for establishing barriers and enablers. The findings may also assist other population-based cancer registries considering collecting cancer stage at diagnosis.

Staff perspectives on end-of-life care for people living with dementia in residential aged care homes: qualitative study

Introduction

People living with dementia in care homes can benefit from palliative approaches to care; however, not all will require specialist palliative care. The generalist aged care workforce is well placed to provide most of this care with adequate training and support systems in place, but little is known about their experiences.

Objective

To describe staff perspectives on providing quality end-of-life care for people living with dementia in residential care and their families.

Methods

Focus groups and semi-structured interviews were conducted with residential aged care managerial and frontline staff in Australia who were caring for residents living with dementia and end-of life needs. A comprehensive, then snowballing sampling strategy was used in participating care homes. Transcripts were analyzed using reflexive thematic analysis.

Results

Fifteen semi-structured interviews and six focus groups were undertaken with 56 participants across 14 sites across two Australian states. Five themes were identified: putting the resident at the center (creating homes not hospitals, knowing the individual, a case management approach); articulating goals to grant wishes (initiating the conversation, broadening death literacy, avoiding hospitalization); a collective call to action (staffing the home, recognizing deterioration and escalating issues, communication channels and engaging GPs, managing medications, psychosocial supports); educating to empower staff (governance and guidance, mentoring juniors, self-care); and facilitating family acceptance (setting expectations, partnering in care, access at all hours).

Discussion

Aged care staff are committed to providing person-centered palliative and end-of-life care for people living with dementia, recognizing the intrinsic value of each resident, regardless of their declining state. Frontline and managerial staff consider advance care planning, collectively working as part of a multidisciplinary team, access to targeted palliative and end-of-life education and training, and engaging families as key priorities to providing high quality care in care homes.

Video Conferencing With Residents and Families for Care Planning During COVID-19: Experiences in Canadian Long-Term Care

BACKGROUND AND OBJECTIVES

Government-mandated health and safety restrictions to mitigate the effects of coronavirus disease 2019 (COVID-19) intensified challenges in caring for older adults in long-term care (LTC) without family/care partners. This article describes the experiences of a multidisciplinary research team in implementing an evidence-based intervention for family-centered, team-based, virtual care planning-PIECESTM approach-into clinical practice. We highlight challenges and considerations for implementation science to support care practices for older adults in LTC, their families, and the workforce.

RESEARCH DESIGN AND METHODS

A qualitative descriptive design was used. Data included meetings with LTC directors and Registered Practical Nurses (i.e., licensed nurse who graduated with a 2-year diploma program that allows them to provide basic nursing care); one-on-one interviews with family/care partners, residents, Registered Practical Nurses, and PIECES mentors; and reflections of the academic team. The Consolidated Framework for Implementation Research provided sensitizing constructs for deductive coding, while an inductive approach also allowed themes to emerge.

RESULTS

Findings highlighted how aspects related to planning, engagement, execution, reflection, and evaluation influenced the implementation process from the perspectives of stakeholders. Involving expert partners on the research team to bridge research and practice, developing relationships from a distance, empowering frontline champions, and adapting to challenging circumstances led to shared commitments for intervention success.

DISCUSSION AND IMPLICATIONS

Lessons learned include the significance of stakeholder involvement throughout all research activities, the importance of clarity around expectations of all team members, and the consequence of readiness for implementation with respect to circumstances (e.g., COVID-19) and capacity for change.

Using the Consolidated Framework for Implementation Research to Foster the Adoption of a New Dementia Education Game During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

The pandemic of coronavirus disease 2019 challenged educators to move staff education online and explore innovative ways to motivate learning to support dementia care for patients in geriatric settings. This article presents how the Consolidated Framework for Implementation Research (CFIR) was used to support the adoption of an online dementia education game in Canadian hospitals and long-term care homes (LTC). The dementia education was codeveloped with local staff and patient partners to teach practical person-centered care communication techniques.

RESEARCH DESIGN AND METHODS

CFIR guided our strategy development for overcoming barriers to implementation. Research meetings were conducted with practice leaders, frontline health care workers, and a patient partner. Our analysis examined 4 interactive domains: intervention, inner context, outer settings, and individuals involved and implementation process.

RESULTS

Our analysis identified 5 effective strategies: Easy access, Give extrinsic and intrinsic rewards, Apply implementation science theory, Multiple tools, and Engagement of champion. The CFIR provided a systematic process, a comprehensive understanding of barriers, and possible enabling strategies to implement gamified dementia education. Interdisciplinary staff (n = 3,025) in 10 hospitals and 10 LTC played online games. The evaluation showed positive outcomes in knowledge improvement in person-centered dementia care.

DISCUSSION AND IMPLICATIONS

Gamified education in dementia care offers a social experience and a component of fun to promote adoption. In addition, CFIR is useful for engaging stakeholders to conduct project planning and team reflection for implementation. The real-time discussion and adjustment helped overcome challenges and timely meet the needs of multiple organizations.

Nurses Barriers to Evidence-Based Practice in Palliative Care: A Systematic Review

Background

Research shows low evidence-based practice (EBP) uptake among palliative care nurses, a global concern because the demand for palliative care services is rising, raising the urgent need to improve healthcare quality. Promoting EBP uptake in palliative care can improve healthcare quality. This systematic review investigated nurses’ barriers to EBP implementation in palliative care.

Methods

PubMed, MEDLINE, CINHAL, and Google Scholar were used to identify seven articles. Articles were included for review if they were published within the past 10 years (English only) and investigated barriers to EBP implementation in palliative care.

Results

Four barriers were identified: (a) time and resource constraints, (b) lack of readiness for organizational change, (c) negative attitudes toward palliative care, and (d) process-specific difficulties.

Conclusion

This systematic review's findings can inform policy changes to improve the uptake of EBP in palliative care.

Evaluating the use of participatory action research to implement evidence-based guidance on dementia palliative care in long-term care settings: A creative hermeneutic analysis

BACKGROUND

Dementia affects a large proportion of society and places a significant burden on older people and healthcare systems internationally. Managing symptoms at the end of life for people with dementia is complex. Participatory action research can offer an approach that helps to encourage implementation of evidence-based practices in long-term care settings.

METHODS

Three evidence-based guidance documents (pain assessment and management, medication management, nutrition and hydration management) were introduced in three long-term care settings for older people. Data generated from work-based learning groups were analysed using a critical hermeneutic approach to explore the use of participatory action research to support the implementation of guidance documents in these settings.

RESULTS

Engagement and Facilitation emerged as key factors which both enabled and hindered the PAR processes at each study site.

CONCLUSIONS

This study adds to the body of knowledge that emphasises the value of participatory action research in enabling practice change. It further identifies key practice development approaches that are necessary to enable a PAR approach to occur in care settings for older people with dementia. The study highlights the need to ensure that dedicated attention is paid to strategies that facilitate key transformations in clinical practice.