No tension, no change? -  Use and influencing factors of a Dutch nursing guideline on Activities of Daily Living (ADL) – a pilot implementation study

doi:10.21203/rs.3.rs-2966413/v1

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Research Article

No tension, no change? - Use and influencing factors of a Dutch nursing guideline on Activities of Daily Living (ADL) – a pilot implementation study

https://doi.org/10.21203/rs.3.rs-2966413/v1

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Background

Care for activities of daily living (ADL) performed by nursing professionals is poorly informed by scientific evidence. To address the nursing professionals’ need for guidance, we developed a clinical practice guideline on ADL care. This guideline comprises key recommendations (KRs) on involving care receivers and informal caregivers in ADL care, identifying ADL care needs, and effective ADL interventions. With the actual guideline use depending on different factors, insight into these influencing factors is necessary prior to the actual implementation. In a pilot implementation, we aimed to measure the use of KRs in various relevant care settings and to identify and explore these influencing factors.

Methods

In a pilot implementation study, mixed methods were applied where (1) nursing professionals weekly and retrospectively registered the frequency of the used key recommendations in a three-week period; (2) a survey was used to identify impeding and facilitating factors; and (3) focus groups were conducted to explore additional factors and how they influence KR use. Descriptive analysis was performed on registration and survey data, while focus group data was analyzed deductively.

Results

Seven nursing care teams participated from the hospital (n = 1), rehabilitation (n = 2), home-care (n = 1), and long-term care (n = 3). The use of KRs varied between KRs and across care settings, with the most frequently used KRs being on involving care receivers in ADL related care choices. KRs were least applied to assessing ADL functioning. The survey on factors influencing the implementation showed how the majority of factors across domains and care settings were generally perceived as facilitating, including the inner setting, the innovation itself, and individuals. Impeding factors mainly related to low tension for change and limited personal benefits. Additional constructs addressed in six focus group sessions included innovation characteristics (e.g. procedural clarity) and cooperation with care receivers.

Conclusions

The KRs generally appear implementable across care settings, with limited factors hindering the KR use. Despite the impression that the KRs are generally perceived as highly compatible with current norms and workflows, low tension for change raises questions on the awareness of current opportunities for improvement in ADL nursing care.

Supporting and respecting a person’s ability to manage their ADL, regardless of diagnosis, cultural background, or healthcare is seen as the most indispensable care provided by nursing professionals (1, 2). However, evidence on how to provide ADL care, adequately and effectively is insufficient (3, 4). As a result, nursing professionals need integral scientific knowledge and guidelines to apply in the delivery of ADL nursing care (5).

Despite a growing number of clinical practice guidelines (CPGs) being developed, the actual success of these CPGs hinges on their actual use by healthcare professionals in practice. Implementing guidelines and changing practices are considered difficult and complex processes (6, 7). Many factors that are regarded as either barriers or facilitators often play a role in the success or failure of the implementation of CPGs (8, 9). Influencing factors might relate to the innovation itself (e.g. the guideline), the individuals using the guideline (e.g. their competencies, attitudes), the inner setting (e.g. care organization or team), or the outer setting (e.g. health system) (10). Also, other aspects of the actual procedure and actions taken to implement a guideline into practice, such as the planning, execution, and procedures, are equally important (11). On the individual level, influencing factors include the nursing professionals’ attitude, knowledge, and beliefs about the CPG (7, 12) and learning through social processes such as group interactions, collaboration, and teamwork (7). Influencing factors on an external level, for example, comprise the level of integration of guideline recommendations into organizational structures and processes (7, 13), organizational leadership and culture (7, 14) education and training (13), resources, and leadership (time/staffing/workload) (7, 12, 13). These factors often lay beyond the control of the nursing professional.

Guideline recommendations that are easily implemented in one environment might not work in another. Therefore, insight into the potential influencing factors in different settings is necessary before the actual implementation. One method for assessing the factors influencing the implementation is pilot implementation studies (15). Eventually, these studies inform so-called ‘implementation strategies’ that improve implementation and sustainable use of innovations (16, 17). Hence, the implementation of a CPG should be well-designed, well-prepared, and preferably tested before use to increase adherence to guidelines in daily nursing practice (8). ADL nursing care is being provided to a diverse patient population in a broader scope of care settings. Hence, knowing that the characteristics of the CPG itself and how it is perceived in a given context greatly determine the implementability of the CPG, understanding these factors is critical for large-scale implementation.

In the Netherlands, the Dutch Nursing Association prioritized the development of a clinical practice ADL guideline for nursing professionals (18). A CPG on ADL nursing care has been developed (see 2.2) according to national and international standards for guideline development (19, 20).

In a pilot implementation, this study aims to:

Measure utilization of the key recommendations of the ADL Clinical Practice Guideline relevant care settings.

Identify and explore impeding and facilitating factors that influence the use of the key recommendations from the ADL clinical practice guideline.

Design:

We conducted a pilot implementation study guided by Pearson, Naylor (15). We applied mixed-methods by (1) tracking the use of recommendations and (2) surveying the factors that promote or hinder recommendation use. Additionally, a qualitative approach using (3) focus group interviews allowed us to gain an in-depth insight into the use of key recommendations and their influencing factors. In reporting our study, we followed the guidelines of Levitt, Bamberg (21). Before commencing the study, we obtained ethical approval from the internal ethics board of the [annonomized due to blinding purposes] We collected data from January 2022 until April 2022.

The Clinical practice guideline on ADL nursing care:

With ADL nursing care being scarcely informed by scientific evidence, relying on professional intuition and experience results in an unwarranted variation in care provision. To support nursing professionals in providing and underpinning ADL care provision, we developed a CPG on ADL nursing care. according to national and international standards (19, 20). More information on the development process can be found in Cremer, Bleijlevens (18). The CPG on ADL nursing care comprises five guideline modules on (1) involving care receivers and informal caregivers in ADL related care choices (2) identifying ADL care needs; (3) effective ADL interventions targeting independence and comfort; (4) supporting and collaborating with informal caregivers, and (5) using ADL care for the detection of health risks. We summarized the most important recommendations of the CPG in 11 key recommendations (KRs). These KRs were organized according to the steps of the nursing process that guide nursing professionals from assessing ADL care needs to planning and evaluating the care provided (22) (see Table 1). This overview of KRs is displayed in the first part of the guideline as a summary for nursing professionals, including references to the modules where more information on the KRs is provided. The KRs of this guideline were tested in this pilot implementation.

Table 1

Key recommendation (KR) of the CPG on ADL nursing care in the nursing process
Nursing process phase 1–3 (1) Data collection, (2) Identification of ADL preferences, needs, and problems (3) Goal setting
KR 1 Care relationship	In all moments of contact with the care receiver, strive to establish a care relationship based on trust, respect, equality, and shared responsibility.
KR 2 Subjective data	During an intake, identify the ADL related habits and experienced complaints of the care receiver (subjective data), and document these in the care file.
KR 3 Objective data	Use the Barthel Index (BI) to assess the degree of ADL independence of the care receiver (objective data). When interpreting the BI, be aware of possible ceiling effects. For example, if, care recipients already score high in the BI during intake, the measurable progress may be limited because the maximum attainable score is reached (ceiling effect). Record the Barthel Score in the care record.
KR 4 Contextual data	Map out the social and physical environment of the care receiver (contextual data) through a conversation with the care receiver and targeted observations of the living environment, and record them in the file.
KR 5 Shared goal-setting	Involve the caregivers in setting ADL goals by a) identifying the care receivers’ (changing) motivations on ADL; b) informing the care receivers about issues that are important from professional expertise around ADL care; and c) formulating ADL goals with the care receivers whenever possible.
KR 6 Informal caregiver skills	In a conversation with the caregivers, explore the extent to which the informal caregivers feel competent and have the knowledge and skills to support the care receivers in ADL care.
Nursing care process phase 4–6 (4) identification and planning of care actions and intervention; (5) carrying out activities and interventions; and (6) evaluating and, if necessary, adjust care and support.
KR7 Shared care agreements	Involve the care receiver in agreeing on care actions and interventions by a) emphasizing that care receiver had a voice in choices around ADL and b) discussing these ADL care options and collaboratively making these care agreements and documenting them.
KR8 Involvement in intervention and evaluation	Involve the care receiver in planning and evaluating the care actions and interventions performed.
KR9 Bathing interventions	Consider applying the principles of the interventions “Person Centred Bathing” and “Bathing Without a Battle” to reduce agitation and discomfort in persons living with dementia in nursing homes.
KR10 Function Focused Care	Consider applying the principles of the Function Focused Care interventions (FFC) to increase the level of ADL independence of people living with dementia in a nursing home.
KR11 Informal caregiver support	Support the informal caregiver during ADL care moments in collaboration with the care receiver.

After development a ‘commentary phase’ took place. In this phase, different stakeholders (caregiver and or care providers and/or representatives, policy makers or educators) provided feedback on the entire guideline document, including the procedural clarity, correctness, completeness, complexity, and relevance for client regarding the recommendations. Based on the received feedback and comments, we adapted the guideline accordingly before the pilot implementation.

[INSERT Table 1]

Participants and recruitment:

For our study, we recruited existing nursing teams from the various care settings relevant to ADL care, including hospital (n = 2), rehabilitation (n = 2), intuitional long-term care facilities (nursing home, care for intellectually disabled adults) (n = 4), and home care (n = 1). The teams consisted of registered nurses (RNs) and (certified) nursing assistants ((C)NAs). We also recruited the manager from one care team, as they play a crucial role in translating the KRs into ADL care processes. We distributed a call for participation within the Dutch Nursing Association and the author’s network to recruit participating teams. We planned online meetings to discuss the purpose and mutual expectations of the pilot implementation with interested nursing professionals and/or managers who responds to the call. Additionally, we sent an information letter describing the study aim and data collection processes and consent forms, which we received back prior to the start of the implementation. All teams that signed up were able to participate, and the nursing professionals were asked to implement the KRs in a group of at least eight care receivers.

Data collection:

At the time of data collection (January 2022 until April 2022), the Netherlands was affected by COVID-19 and in lockdown. Therefore, all contact with the participants and instruction exclusively took place online. Before implementation, we sent a summary version of the guideline with the 11 KRs and included a summary of the guideline modules to the team manager. We instructed the manager to embed the processes of the pilot implementation in day-to-day operations. This includes putting the pilot implementation on the agenda of team meetings and drawing attention to and reminding them of the key recommendations. The researchers did not interfere with the processes of how the manager chose to introduce the KRs within the care teams.

Weekly registration of used KRs:

Nursing professionals self-reported the use of KRs in a three-week period and received this list prior to implementation from their manager who distributed and collected these lists after each week of implementation. After each week, we asked nursing professionals to register which KR they applied in the past 7 days for each care receiver in a registration list (see example in Table 2). Care receiver data were anonymized in the lists.

Table 2

Example of the weekly registration matrix to poll use of key recommendations (KR) per care receiver (CR)
W1	Name			Nursing qualification				Date:
	KR 1 care relationship	KR 2 subjectieve data	KR 3 objectieve data: Barthel index	KR 4 contextual data	KR 5 shared goal setting	KR 6 informal caregiver skills	KR 7 shared care agreements	KR 8 shared care actions	KR 9 bathing intervention	KR 10 function focused care	KR 11 informal caregiver support
CR Nr.
CR Nr:

[INSERT Table 2]

Survey on influencing factors:

After three weeks, participants completed a self-developed survey on the facilitating and impeding factors based on a selection of the Consolidated Framework for Implementation Research (CFIR) (23) and the Dutch Measurement Instrument for Determinants of Innovations (MIDI) (24). The CFIR consists of 39 underlying components and sub-constructs that are divided into five domains (intervention features, outer setting, inner setting, characteristics of individuals, and process) that may influence change in practice (23). Similarly, the MIDI questionnaire comprises 29 items divided into four domains related to 1) the innovation, 2) the potential user of the innovation, 3) the organization where the potential user works, and 4) the socio-political context. We selected this questionnaire since it overlaps as well as adds construct to the CFIR constructs, and its questions were translated and tested in the Dutch setting (24). We selected constructs that we considered close to the daily work reality of nursing professionals, relevant to using the KRs in practice while accounting for the length of the survey. The constructs mainly originated from the domains concerning the innovation itself, the inner setting, and the individuals using the KRs. The selection of relevant constructs was made after several discussions among the authors until consensus was reached. Eventually, we selected 18 constructs, of which nine constructs overlap in both sources, seven originate from the MIDI, and two are described in the CFIR. We displayed the selected constructs in Table 5.

Table 5

Facilitating and impeding factors of KR use based on the survey and focus group sessions
Characteristics of the inner setting				Characteristics of the innovation
		N	N %			N	N %
Tension for Change¹	Facilitating	6	15.8	Relative Advantage ¹	Facilitating	153	75.7
	Impeding	24	63.2		Impeding	8	4.0
	Neither/nor^*	8	21.1		Neither/nor^*	41	20.3
Social Support Management²	Facilitating	26	68.4	Adaptability ^1,2	Facilitating	180	89.1
	Impeding	4	10.5		Impeding	7	3.5
	Neither/nor^*	8	21.1		Both	15	7.4
Social Support colleagues ²	Facilitating	28	73.7	Complexity ^1,2	Facilitating	161	79.7
	Impeding	4	10.5		Impeding	16	7.9
	Neither/nor^*	6	15.8		Neither/nor^*	25	12.4
Subjective Norm Management ^1,2	Facilitating	26	68.4	Total innovation	Facilitating	659	81.6
	Impeding	1	2.6		Impeding	40	5.0
	Neither/nor^*	11	28.9		Neither/nor^*	109	13.5
Subjective Norm Colleagues ^1,2	Facilitating	20	52.6	Characteristics of the individual
	Impeding	2	5.3	Knowledge ^1,2	Facilitating	177	87.6
	Neither/nor^*	16	42.1		Impeding	4	2.0
Time ^1,2	Facilitating	136	67.3		Neither/nor^*	21	10.4
	Impeding	26	12.9	Outcome expectations (Probability) ²	Facilitating	181	89,6
	Neither/nor^*	40	19.8		Impeding	5	2.5
Staff capacity ^1,2	Facilitating	123	60.9		Neither/nor^*	16	7.9
	Impeding	24	11.9	Outcome expectations (Importance) ²	Facilitating	187	92.6
	Both	55	27.2		Impeding	3	1.5
Compatibility ^1,2	Facilitating	165	81.7		Neither/nor^*	12	5.9
	Impeding	9	4.5	Self-Efficacy ^1,2	Facilitating	174	86.1
	Neither/nor^*	28	13.9		Impeding	1	0.5
Total inner setting	Facilitating	365	61.4		Neither/nor^*	27	13.4
	Impeding	85	14.3	Professional obligation ²	Facilitating	189	93.6
	Neither/nor*	144	24.2		Impeding	3	1.5
Constructs added based on focus group sessions					Neither/nor^*	10	5,0
Characteristics of the innovation				Personal benefit ²	Facilitating	140	69.3
• Procedural clarity • Completeness • Design Quality and Packaging				Personal benefit ²	Impeding	62	30.7
Characteristics of the individual				Personal drawback ²	Facilitating	187	92.6
• Client/patient cooperation • Knowledge and Beliefs				Personal drawback ²	Impeding	15	7.4
				Total individual	Facilitating	1235	87.3
					Impeding	93	6.6
					Neither/nor^*	86	6.1
				Total
				Total all factors	Facilitating	2259	80,2
					Impeding	218	7,7
					Neither/nor^*	339	12,0
^* Neither facilitating nor impeding ¹ Based on the Consolidated Framework for Implementation Research (CFIR) [23] ² Based on the Measurement Instrument for Determinants of Innovations (MIDI) [24]

Nursing professionals who used the specific KRs during the pilot implementation were able to fill in the questions. We used a five-point Likert scale ranging from (1) totally disagree to (5) totally agree as options to answer the questions about the influencing factors. The survey was built and distributed in Castor EDC using the mail addresses of the participating nursing professionals. We asked them to complete the survey within seven days after the final registration in third week to limit recall bias in the following focus groups. We also sent a reminder after five days.

Focus groups perceptions on influencing factors:

After receiving the weekly registration forms and surveys from the teams, we scheduled focus group meetings with each participating team to discuss the results with the participants and to gain more insight into why some factors worked in a facilitating or impeding way. In addition, we used the focus group to obtain additional information about the context of the ADL care in question. Prior to conducting the focus groups, we built a topic guide for each individual care team comprising general open questions on the experience of pilot testing the guideline and questions related to the results of the weekly registration forms. For this purpose, the first and the last author reviewed the results of the weekly registration forms and surveys of each care team to add context-specific questions to the developed topic guide. Due to COVID-19, we used ZOOM (Zoom Video Communications Inc.) to conduct the focus group sessions online, which were then audio-recorded by a manual voice recorder.

Data analysis:

Weekly registration:

Before analyzing the data, we transferred the polled used KRs into Microsoft Excel to digitalize all registration matrixes manually. For data processing, we used codes for nursing professionals and care receivers to guarantee anonymity throughout the process of analysis. In creating the codes, we indicated the setting and organization of the person in question. To analyze the data, we calculated descriptive data in Excel, including totals and average use per organization, setting, and in total.

Survey on influencing factors:

After exporting the survey responses from Castor EDC and importing them into IBM SPSS Statistics v.27, we used descriptive statistics to describe the general study population and the total and mean responses from the participants. We did not include partially completed surveys in our analysis. To further analyze the data, we merged the five-point Likert scale into a three-point scale by calculating sum scores of the categories (1) Strongly disagree and (2) Disagree, as well (4) Agree and (5) Strongly agree into new categories. Category (3) ‘neither impeding nor facilitating’ remained the same. This step resulted in an overview of scores indicating the extent to which a factor was perceived as impeding, neither impeding nor facilitating, or facilitating.

Focus groups:

Prior to analysis, we transcribed the audio-recordings of the six focus groups and extracted data from the open-ended survey questions. We then analysed the transcripts applying techniques of qualitative content analysis, guided by a deductive approach (25), as we aimed to analyze our data in light of an existing framework. Hence, we created a codebook inspired by the CFIR codebook template, in which we imported operationalizations of constructs from CFIR and MIDI into MAXQDA as a deductive template for content analysis. As a first step, the first author familiarized herself with the data to gain a deeper understanding. Subsequently, she systematically generated initial codes of the data using MAXQDA. From initial coding, she moved forward to descriptive categories and subcategories that were, where applicable, assigned to existing constructs. During the process of analyzing the data, she kept an open mind to possible other constructs and categories that were then added to the predefined constructs in the codebook.

Participants:

In total, 62 participants took part in the pilot implementation. We displayed further specifications on the participants per phase of data collection in Table 3.

Table 3

Overview of participants per setting and phase of data collection.
Setting	Organisation	Occupation¹	Total number of participants² n = 62	Participants of registration (n = 46)	Survey participants (n = 44)	Focus group participants (n = 25)
All settings		Team manager	6	1	3	4
		RN	24	16	14	5
		CNA	11	12	10	7
		NA	2	2	1	1
		RN Intern/student	10	10	9	5
		Personal support worker	8	4	2	2
Home care		Team manager	1	0	1	1
		RN	1	1	1	1
		CNA	1	1	1	1
		NA	1	1	1	1
		RN Student/intern	1	2	2	2
Acute and subacute care	Geriatric rehabilitation	Team manager	1	0	0	1
		RN	4	4	4	1
		CNA	2	2	1	2
	Stroke rehabilitation	Team manager	1	0	0	0
		RN	5	0	5	0
		RN student/intern	3	3	3	3
	Hospital care (mixed ward)	RN	8	8	4	0
	Hospital care (mixed ward)	RN student/intern	3	3	3	0
Long term care	Nursing Home 1	Team manager	1	1	1	1
		RN	1	1	0	1
		CNA	5	5	5	2
		RN Student/intern	1	1	1	0
	Nursing Home 2	Team manager	1	0	1	1
		RN	4	1	4	1
		CNA	4	4	3	2
		NA	1	1	0	0
		RN Student/intern	2	2	0	0
	Care for intellectually disabled adults	Team manager	1	0	0	0
		RN	1	1	1	1
		Personal support worker	8	4	2	3
¹ Registered Nurse (RN); Certified Nursing Assistant (CNA), Nurse assistant (NA) ² The number of participants per data collection may overlap so these numbers are not a cumulative summation of the number of participants per point of data collection.

[INSERT Table 3]

Weekly registrations:

During the three-week period, 46 participants applied in total 2565 KRs. The number of applied KRs varies widely, ranging from 111 to 393 times. Generally, the use of KRs varies significantly across all KRs. The KRs on involving care receivers in ADL related care choices were applied most often across care settings. Four out of the five most applied KRs were KRs on involving care receivers in ADL care, including working (1) towards an equal collaborative relationship (KR1: 619); (2) involving care receivers in care actions (KR8: 435); (3) Shared goal setting (KR5: 272); Shared care agreements (KR7: 264). Additionally, the KR on Function Focused Care (FFC) belonged to the top three of the most applied KRs (KR10: 273). Focus group sessions added information on how involving care receivers in ADL related care choices largely aligns with current norms, values, workflows, and organizational developments (see compatibility).

The KRs that were used the least are those on identifying the level of ADL independence using the Barthel Index (KR3: 66 [0–26]) and identifying the capacity of informal caregivers on supporting the care receiver in ADLs (KR6: 48 [0–18]). Focus group discussions revealed that ADL functioning is often not routinely assessed, especially in community or long-term care settings. In hospital or rehabilitation settings, Dutch health insurance requires periodic assessment of ADL functioning. Whereas community or long-term care organizations did not choose to assess and consequently did not provide either assessment forms or digital infrastructure. In some cases, the ADL assessment is taken over by other disciplines, e.g., occupational of physiotherapists. We presented an overview of the applied KRs within and across care settings in Table 4.

Table 4

Overview of registered use of KRs within and across care settings and organizations
Setting	Organization	N		KR 1 care relationship	KR 2 subjectieve data	KR 3 objectieve data: Barthel index	KR 4 contextual data	KR 5 shared goal setting	KR 6 informal caregiver skills	KR 7 shared care agreements	KR 8 shared care actions	KR 9 bathing intervention	KR 10 function focused care	KR 11 informal caregiver support	Total
All settings	All organizations	42	Total	619	200	66	79	272	48	264	435	258	273	71	2565
All settings	All organizations	42	% of total KRs used	24,1	7,8	2,6	3,1	10,6	1,9	10,3	17,0	10,1	10,6	2,8	100
Home care		5	Total	122	2	0	0	9	0	7	120	3	0	0	263
Home care		5	% of total KRs used	46,4	0,8	0	0	3,4	0	2,7	45,6	1,1	0	0	100
Acute and subacute care	Hospital	11	Total	57	27	14	26	60	13	56	55	32	50	3	393
	Hospital	11	% of total KRs used	14,5	6,9	3,6	6,6	15,3	3,3	14,2	14	8,1	12,7	0,8	100
	Neuro-rehabilitation	3	Total	41	14	3	4	13	2	12	9	3	9	1	111
	Neuro-rehabilitation	3	% of total KRs used	36,9	12,6	2,7	3,6	11,7	1,8	10,8	8,1	2,7	8,1	0,9	100
	Geriatric rehabilitation	6	Total	55	28	22	8	40	6	40	45	20	20	0	284
	Geriatric rehabilitation	6	% of total KRs used	19,4	9,9	7,7	2,8	14,1	2,1	14,1	15,8	7	7	0	100
Long-term care	Nursing home 1 + 2	16	Total	186	46	26	30	49,0	18,0	52,0	167,0	43,0	42,0	21,0	577,0
	Nursing home 1 + 2	16	% of total KRs used	32,2	8,0	4,5	5,2	8,5	3,1	9,0	28,9	7,5	7,3	3,6	100,0
	Care for intellectually disabled adults	5	Total	82	17	0	1	5	0	12	45	42	30	0	234
	Care for intellectually disabled adults	5	% of total KRs used	35	7,3	0	0,4	2,1	0	5,1	19,2	17,9	12,8	0	100

[INSERT Table 4]

Facilitating and impeding factors of KR use:

In our survey, we identified the factors influencing the use of KRs regarding the inner setting (i.e., the care organization or team), the innovation (i.e. the KRs), and the individuals (nursing professionals) applying the KRs. Overall, our results show that the majority of factors influencing the KR use are perceived as facilitating with 80.2% (n = 2259). More specifically, characteristics regarding the individuals were perceived as the most facilitating with 87.3% (n = 1235), followed by characteristics of the innovation with 81.6% (n = 659). Inner setting characteristics scored the least facilitating with 61.4% (n = 365). In the section below, we illustrate the results of the factors we surveyed, as well as the additional factors participants addressed in the focus group sessions.

[INSERT Table 5]

Characteristics of the inner setting:

General inner setting:

The constructs that stand out the most in the inner setting domain are the low tension for change and the high degree of compatibility. Tension for change appears to be most impeding since 63.2% (n = 24) of the participants do not feel the urgency for the ADL care situation to change, in contrast to the 15.8% (n = 6) who do. This result might align with the perceived high-level compatibility scored as the most facilitating with 81.7% (n = 165). The focus group sessions confirmed the impression of the KRs being close to the norms and values of person-centered ADL care. Participants express how the vision on care evolved towards person-centered care and in line with the KRs as the following nursing professionals explains:

“I also see a development in the care we provide. Because I've been working in healthcare since 1985. […] And I've noticed that in the past, as soon as you walked in the door of a nursing home, the control was within the nursing home, and as a resident or client, or whatever you want to call it, you had very little insight into what one could or could not do. Much more attention was paid to the structure of a ward, what fitted in. And now we have to look the other way around" [CNA, Nursing home care].

In terms of workflow, we see that depending on the KR, nursing professionals generally feel that the KRs are ‘not being anything new’ and in line with ‘what one does on a daily basis anyways.’ They were largely perceived to be in line with their daily work when it comes to involving the care receiver in ADL related care choices or stimulating independence in ADL care.

On a different note, focus group sessions revealed how, depending on the care setting, KRs were less compatible regarding assessing ADL functioning or involving informal caregivers in the actual care. Whether or not nursing professionals assess ADL functioning seems to depend on the organizational choice, especially in long-term care settings, where an ADL assessment is not a requirement from an insurance company, for example. Moreover, reporting subjective, objective, and contextual data depends on the structure of electronic patient dossiers (EPDs), which can differ per organization.

KR-specific inner setting characteristics:

We separately surveyed other constructs such as ‘time’ and ‘staff capacity’ as part of the inner setting for each KR. The responses showed that time was generally perceived as facilitating, with a score 67.3% (n = 136) across all KRs. KR8 was the only KR where time was perceived as more impeding, with a score of 21.7% (n = 5). The focus group sessions revealed a tension between the perception of involving caregivers in actions and encouraging autonomy, which takes more time. However, it could save time in the long term if colleagues act consistently, as this nursing professional explains:

“Well, I also think you need to be on the same page with colleagues. For example, if I ask a resident, who can still do a lot of things independently, to wash their face, I expect my colleagues to do the same the next day. Otherwise, you end up with a ‘wait-and-see attitude,’ like, hello, yesterday Johnny did everything for me and now you want me to wash my face. So you don't gain any time. But if you can get a resident to do it themselves, I think you can save some time” [CNA, Nursing Home care].

Staff capacity was generally perceived as less facilitating, with a score of 60.9% (n = 123), and was also addressed as a major issue in the focus group sessions. Issues raised by focus group participants mainly evolved around workload due to staff shortages that even have been exacerbated by COVID-19. One nursing professional expresses the hope of being able to change the way of ADL care when the team is complete again:

“We all have good ideas all in us, and we would like to change. But, right now we have four instead of eight colleagues. And we've all just had COVID. It's all not going the way we want, actually. So, at the moment, we can't do very much yet. But, I think when we will soon have the team complete again, we will find the turn well for certain things. Just keep going, and you'll get the good things out of it. But, you need a good team for that, indeed” [RN, Care for Adults with Intellectual Disabilities].

Characteristics of the innovation:

In our study, the characteristics of the innovation scored relatively high, with a total score of 81.6% (n = 695) facilitating. This result might create the impression that the innovation is generally well adaptable, not too complex, and an advantage over alternatives. However, focus group sessions revealed additional constructs related to the innovation, among which procedural clarity was highlighted. Despite the KRs’ procedural clarity generally being perceived as facilitating, hindering aspects included wording and sentence structures at some instances. Nursing professionals recognized the challenge of being complete and clear in the formulation of KRs while also being concise, as this nursing intern illustrates:

“In itself, I found what was written clearly understandable. Now it takes, say, so much time […]... So I can imagine, if it is perhaps even more concise ... We had also received a summary per KR, which is again a bit too concise, but somewhere in the middle, you can find some extra explanation, I can imagine. But in itself, how it was written down, I thought it was pretty clear” [RN intern, Neuro rehabilitation].

Additionally, based on the focus group data, we added the construct of completeness, which was especially perceived as hindering in KRs on interventions lacking a clear and complete description of the steps to be taken in order to be performed (KR9, 10).

"If this core task can provide calmness to the care receiver, then I think this is a good one to apply. Yet, I also find it difficult and would like to know more about it" [CNA, nursing home].

In terms of the design and packaging of the KRs, nursing professionals found perceived overlap of information in the KRs to be hindering. For example, overlap of information on involving care receivers in different steps of the nursing process came at the expense of readability.

"‘I also spent quite a long time reading it because a lot of things were similar. I don't know if you had that too, that there were repetitions, maybe in it, well, not really repetitions, but overlap, that key recommendation especially the first few, are quite similar.” [Community Nurse].

Moreover, the presentation of KRs did not allow all nursing professionals to locate the information they were looking for immediately.

Characteristics of the individual:

Nursing professionals generally attribute the most facilitating factors to their individual characteristics with a mean of 87.3% facilitating (n = 1235). Of all the individual characteristics we surveyed, the professional obligation was perceived as most facilitating with 93.6% (n = 189); (impeding: 1.5%, n = 3). Despite providing ADL care, including observing and documenting changes, is perceived as part of the profession, focus group results show that certain roles within the nursing profession perceive a different obligation towards certain KRs. Nursing professionals fulfilling additional roles in intake processes or supporting during a transition from home to nursing home adhering to KRs on identifying and monitoring ADL care needs contributes to the professional obligation. Additionally, the role of other disciplines was discussed in focus groups. Nursing professionals explained that occupational or physical therapists routinely assess ADL functioning or investigate the living environment. This limits the contribution from nursing professionals, as this nursing professional explains:

“Our occupational therapist does know the Barthel Index. But, she was also like, ‘Yes, that's my area, and you don't have to do anything with that’” [RN, Care for adults with intellectual disabilities].

In terms of personal benefits and drawbacks, results show that personal drawbacks were not perceived as an issue with a score of 92.6% (n = 187) facilitating (7.4%; n = 15). Personal benefit scores comparatively low with 69.3% (n = 140) facilitating (impeding: 30.7%; n = 62). However, the open-ended questions in the survey and focus group sessions indicate that nursing professionals report beneficial experiences on three levels: (1) the care relationship indicating that working towards a care relationship based on trust, respect, equality, and shared responsibility results in, for example, care receivers sharing their concerns and emotions more easily; (2) care delivery and working climate where nursing professionals experience their care as more person and goal-centered since they feel empowered in clinical reasoning when assessing ADL functioning and using these results to set goals. Regarding the working climate, nursing professionals report that when care receivers feel seen and heard in their ADL care needs, nursing professionals feel less stressed since they don’t have to engage in discussions with care receivers. Additionally, clear documentation results in clear care arrangements among nursing professionals, who can work consistently according to those arrangements. Nursing professionals also report benefits in their (3) Professional development, especially through mutual evaluation and reflection with care receivers on the provided care, leads to points of improvement for the professionals.

“The KRs contribute to my growth process in being a Certified Nursing Assistant is not taking over too much from the care receivers. My lesson is that autonomy is important for the client's self-esteem” [Nursing professional, Nursing Home Care].

Personal drawbacks were reported by some nursing professionals, indicating struggle with frustration or disappointments when they feel unable to address care receiver’s needs. Additionally, they mention that being too close a care receiver can limit the professional ‘objective’ view of the care receiver’s process.

Other characteristics of the individual addressed in the focus group sessions:

The cooperation of care receivers and informal caregivers was a construct that was added after the focus group sessions. This construct was generally perceived as facilitating, especially when applying KR1 and working towards improving the care relationship, or letting care receivers make their own ADL choices (KR 5, 7, 8). Participants perceive this to increase the level of cooperation of care receivers resulting in ‘smoother’ care delivery. A hindering aspect of the cooperation with care receivers or informal caregivers arises when generational gaps or attitudes clash with the care paradigm of younger care professionals who aim to encourage independence.

“But of course, there are different ages of employees. And some find it more difficult to say to an older resident: ‘Well, you'd better try it yourself.’ The resident then thinks, ‘Well, I'm not going to enter into that whole discussion, […] you young thing, you can't do that.’ […] they just outplay each other. And then they [the younger employees] think, I'm not going to have that whole discussion, I'll do it. Because then I'll be done faster” [Community Nurse].

Especially professionals working with intellectually disabled adults highlight that difficulties in collaboration with care receivers due to insecurity of care receivers and old traditions are a hindering factor:

“Well,[…] our residents have also never been […] asked: ‘What do you think is important?" We just had another client who just can't choose what color nail polish she wants because she was never asked, "What do you like?" From back home, huh. So, I think asking: ‘How do you want to be cared for?’ That's a question that goes all over them. I mean, I can ask: "Do you want to take a bath or do you want to shower?" They then sometimes say, ‘What would you do?’ […]” [RN, care for intellectually disabled adults].

Cooperating with informal caregivers was perceived as a delicate when aiming to involve them in ADL care (KRX). Nursing professionals reported a fine line between voluntary involvement and obligation. Nursing professionals appreciate the involvement, while not wanting to increase the burden of informal caregivers. In fact, ADL care by nursing professionals in home care, for example, was reported as a moment in which informal caregivers have time for themselves, as this nurse describes:

"However, many informal caregivers also choose to retreat the moment the nursing professional comes. They are then just happy, like okay, you can take over for a while, I can do something for myself, even if it's a cup of coffee or just take a shower, etc" [Community nurse].

Knowledge and beliefs of nursing professionals were perceived as a facilitating factor when their previous education was in line with the KRs, especially involving care receivers or stimulating independence. Additionally, the KRs helped nursing professionals realize the depth of ADL care and how it contributes to the personhood of the care receiver, as this CNA explains:

"I'm caring for persons with severe dementia, and then you quickly take control yourself. But just then, when I think about this, I see, "This care receiver has special body lotion or she likes to brush her teeth before or after something." […] I became much more aware that it has a lot more depth, and not just that person at that time and that time in this room" [CNA, nursing home care].

Hindering attitudes were mainly characterized by being ‘stuck in old patterns and routines’ and ‘less motivated’ to change their ways of providing ADL care.

In this pilot implementation, we aimed to first measure the utilization of the key recommendations of the CPG on ADL in relevant care settings and second to identify impeding and facilitating factors that influence the use of the selected key recommendations from CPG on ADL. Our results showed that the use of KRs vary across KRs and settings. The most frequently used KRs were on involving care receivers in ADL related care choices. KRs were the least applied on using the Barthel Index to assess ADL functioning and supporting informal caregivers in ADL care. Factors influencing the implementation of KRs were generally perceived as facilitating, including the inner setting, characteristics of the innovation and individuals. However, impeding factors mostly comprise a low tension for change and limited personal benefits. Focus group sessions revealed additional explanations and additional impeding and facilitating factors such as procedural clarity or the collaboration with care receivers and informal caregivers.

When taking a closer look at which KRs were applied, we see KRs on involving care receivers in ADL care are applied the most, especially the KR on working towards a care relationship based on trust, respect, equality, and shared responsibility. This result is consistent with the literature on ADL care as part of fundamental nursing, stressing the importance of the care relationship as foundation for person-centered (26) and quality nursing care (27). At the same time, nursing professionals appear to be challenged by their own routines, task-focused, and time driven approaches (28), limiting their ability to maintain an authentic connection and use a variety of professional knowledge and skills to manage the care. Hence, despite its importance confirmed by our results and literature, establishment this care relationship might remain challenging.

Another crucial part of quality ADL nursing care relates to the clinical reasoning of nursing professionals, specifically the assessment of ADL functioning. Assessing ADL functioning is the least- used KR and appears to be mostly restricted to acute clinical care settings (rehabilitation or hospital care), where organizations and insurance companies require periodic assessments of function. However, in community or long-term care, functional assessments do not seem integrated into the nursing processes, since organizations did not ‘choose for this assessment’ or ‘the EPD does not allow for reporting an ADL assessment. ’ Based on the literature, different factors can account for a proper ADL needs assessment, which accounts for a vital aspect of ADL care. Within the guideline implementation literature, defining organizational barriers related to organizational choices are well recognized, including lacking organizational readiness (29) or lacking administrative support or technology (30). Without the right infrastructure embedded in daily processes, nursing professionals are not enabled to assess ADL functioning. In the Netherlands, requirements of health insurance in (sub) acute care might be the most determining incentive for organizations to regularly assess ADL functioning. In other settings, skilled nursing professionals often intuitively interpret, recognize, and judge symptoms or patterns while bypassing the stages of obtaining relevant information clinical reasoning (31). While intuitively assessing function often happens unconsciously, some nursing professionals experience a lack of knowledge and skills for completing assessments (32) as part of the nursing process. This potentially hinders recognizing the individuality of care receivers (33) and hinders nursing care, as required care may be left undone. This observation highlights the need for functional assessment, even in long-term care settings, to improve clinical reasoning and ultimately achieve quality and person- centered ADL care.

Our findings on facilitating and impeding factors influencing the use of KRs partially align with those in the literature on guideline implementation and extend them in numerous ways. Similar influencing factors are described in literature reviews, where the attitude of care professionals is both impeding and facilitating, depending on the professional or the general lack of personal benefits in nursing professionals (12). While in other studies, nursing professionals mainly report external barriers (up to 91% of sampled nurses), which were mainly organization-based with time, staffing, and workload up to 21% (13). Surprisingly, in our study, the perception of external barriers overall remained relatively low with time being reported as 12.9% impeding and staff capacity as 11.9%. These findings might be explained by the overall perception of nursing professionals acting in line with the CPG already, as shown by the high levels of compatibility (81.7% facilitating) and low tension for change (15.8% facilitating), and the focus group sessions confirming this result.

Our results reveal that nursing professionals, overall, do not feel that the way that ADL care is currently provided needs to change, and that KRs are largely compatible with current norms and workflows. However, given the current literature on fundamental nursing care, this result has to be interpreted with caution. As this type of nursing care undervalued and largely taken for granted (4, 28), the question arises, whether nursing professionals are sufficiently aware of their own practice in considering the complex underlying processes of ADL nursing care. Studies observing nursing professionals’ behavior in ADL show how nursing professionals struggle to actually pay attention to care receiver needs and integrate them into their care processes (34). With ADL being a routine-based and repetitive form of care, there is a risk that nursing professionals are not sufficiently aware of their actions. Literature on self-reflection shows that nursing professionals perceive difficulties in ending the cycle of repetitive, circular thinking through self-questioning (35). Therefore, future research on implementing this CPG on a larger scale should therefore pay specific attention to the implementation process, specifically the process of reflecting and evaluating by involving stakeholders’ own views on their behavior (36) and providing feedback on progress towards objectives as a key behavior change technique (37).

Moving forward to possible strategies for implementation, our results point in the following direction:

First, we suggest improving the KRs in a way in which nursing professionals can easily find the right information, as by using an infographic. Second, future implementation should focus on creating a tension for change by getting insight into the current ADL care and contrasting the aspects that can be improved, announcing a change, and cultivating commitment (38).

Strengths and limitations:

Our study’s strength lies in its breadth of settings, as we conducted it across all settings in which ADL care is provided, including care for intellectually disabled adults. The overall picture we captured is unique since most studies tend to focus on one or at most two settings at a time. This approach has enabled us to shed light on implementation-related knowledge and issues of ADL nursing across care settings, taking into account contextual factors. Moreover, choosing a mixed methods approach allowed us not only to capture the amount of KRs used and the factors influencing the KR use but also to gain additional information on underlying reasons based on our focus group sessions. This approach allowed us to validate the quantitative findings, while understanding how additional factors influence KR use.

However, this study is subject to certain limitations: The use of KRs in practice and their influencing factors relies on the self-judgment of nursing professionals, which comes with a certain level of subjectivity when it comes to the numbers of whether or not a KR was applied or the way in which care receivers were actually involved in decisions. With varying perceptions on actual involvement that differ between care receivers and nursing professionals, it would have been valuable to either include care receivers or to directly observe nursing professionals when applying the KRs. This would have contributed to the picture of the actual number of KR applications.

We designed our survey on influencing factors in a way that allowed participants to answer questions on a specific KR when nursing professionals indicated that they actually used the KR in the last weeks. Consequently, nursing professionals who may have found KRs, for example, too complex to apply, did not assess these KRs in the questionnaire which might have increased the positive picture of influencing factors. However, in focus group sessions, we included the perspective of all nursing professionals, allowing us to identify additional points for improvement in terms of readability and design.

Moreover, the COVID-19 lockdown in the Netherlands during data collection limited our study in two ways. Firstly, the ability of nursing teams to prioritize the registration of KRs was limited in one nursing home, limiting the accuracy of the reported numbers of week two. Secondly, it was not possible to conduct a focus group with the hospital nursing team since the care for COVID-19 infected patients was prioritized. Additionally, COVID-19 has limited the possibilities for involving informal caregivers in ADL care, for example, rehabilitation or nursing home care, through the application of KRs. At the same time, there could be a certain selection bias, considering that those organization participating during a pandemic already consider themselves progressive while prioritizing their ADL care.

In our study, we used the CFIR framework of (23), which was updated after our data collection and first analysis (10). A central change in this updated framework revolves around an improved centering of the innovation recipients (e.g., care receivers) and their values, believes, needs, as well as allowing them to participate in implementation (10). Reflecting on our results, our CPG already advocates for considering the needs of care receivers and involving them in decisions. Moreover, the cooperation of care receivers and nursing professional emerged as an additional influencing factor from the focus group discussions. This central role of care receivers within the innovations should, hence, also be considered during future implementation processes.

Our study makes an important contribution to the literature by describing nursing professionals’ perceptions and experiences of factors that influenced the implementation of the CPG on care for ADL across relevant care settings and organizations. Our results show how KRs on involving care receivers in ADL related care choices are frequently used, while clinical reasoning, more specifically assessing ADL functioning, may contain room for improvement. Despite the impression that the KRs are generally perceived as highly compatible with current norms and workflows, a low tension for change raises questions on the awareness of current opportunities for improvement in ADL nursing care. Moreover, the future implementation should account for contextual differences regarding the assessment of ADL functioning. Future research and implementation should stimulate awareness and critical reflection in routine processes for successful implementation and quality ADL nursing care.

ADL- Activities of Daily Living

CFIR- Consolidated Framework of Implementation Research

CNA- Certified Nursing Assistant

CPG- Clinical Practice Guideline

KR- Key Recommendation

MIDI- Measurement Instrument for Determinants of Innovation

NA- Nurse Assistant

RN- Registered Nurse

Ethics approval and consent to participate

The internal Ethics Committee of the internal ethics board of the Faculty of Health Medicine and Life Sciences (FHML) of Maastricht University approved the protocol for this study. Approval number: FHML-REC/2022/017. Staff received both written and oral information about the study aim and methodology. Written informed consent was signed from all participants before data collection and participants could withdraw from the study at any time. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This research was supported by funding from the Netherlands Organization for Health Research and Development (ZonMw). Grant ID: 516004014.

Authors' contributions

All authors were involved in designing the study. S.C., M.B. built the registration matrixes, survey and topic guide and collected data. S.M. and J.d.M. were involved in planning and validating the methods, S.C., M.B. and S.Z. processed the data, performed the analysis. S.C. drafted the manuscript and designed the figures. S.C. S.Z, and M.B. interpreted the results. All authors discussed the results and reviewed the manuscript in different phases

Acknowledgements

Grateful acknowledgement is made to all nursing tems that have participated in the pilot implementation especially in times of COVID-19.

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No competing interests reported.

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No tension, no change? - Use and influencing factors of a Dutch nursing guideline on Activities of Daily Living (ADL) – a pilot implementation study

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