Characteristic of nursing homes – the context
Seven nursing homes (n=4 intervention groups, n=3 control groups) in two regions of Germany took part in the study. The number of long-term care beds varied between 40 and 171 across the nursing homes. Within the nursing homes, the number of wards ranged from two to six wards, the ratio of nursing staff to residents for skilled nurses was 0.19 in total (cluster-variation between 0.16 and 0.28), and the prevalence of joint contractures varied between 19% and 96%. All nursing homes conducted interprofessional case conferences (five on a regular basis, two on an occasional basis). The services in the local environment varied, but four of the seven nursing homes were in walking distance to parks, stores, churches, and coffee bars. Five of the seven nursing homes have an environment that promotes physical activity with therapeutic gardens or walking circuits. The characteristics of the nursing homes are presented in Table 2.
Process of implementation
Results on the degree of implementation of the PECAN intervention are presented in Table 3. Results on enablers and barriers of the PECAN implementation strategy from the problem-centred interviews are summarised in Table 4.
Out of the 57 persons invited to the problem-centred interviews, 28 persons took part, 13 facilitators (13/14), five relatives (5/24), four therapists (4/13), four social workers (4/4), and the two peer-mentors (2/2). The response was particularly high among internal stakeholders (facilitators and social workers), while only a few external stakeholders (therapists and relatives) responded to the invitation distributed by the head nurse.
The head nurse or nursing home director of each nursing home signed the declaration to ensure their commitment to improve residents’ participation and to support the implementation of PECAN. In the facilitators’ workshop, 14 nurses from two study regions and four nursing homes (2 to 6 nurses per nursing home) were trained as facilitators as planned. All the facilitators fulfilled the predefined qualification criteria and had at least one year of professional experience (range: 1 to 11 years). In addition, seven facilitators had at least one advanced vocational training in nursing (gerontological psychiatry nursing n=2; palliative care nursing n=3; case management n=1; nursing management n=4; clinical instructor n=3). Whereas in clusters 2, 3 and 4 all the facilitators were engaged in daily nursing care on their ward, one of the facilitators in cluster 1 was the deputy nursing home director.
The topics of the workshop were mainly rated as highly relevant for practice (high n=10; partly n=4; low n=0). After the workshop, 13 out of 14 facilitators felt competent to be active in the adaptation of care plans. Further information about the self-assessed preparedness for the role as facilitator is presented in Additional file 1, Table A1. Overall, the quality of the facilitators workshop was rated with 1.7 points (SD 0.45; range: 1 to 2 points), indicating a good acceptance of the workshop.
Findings from the problem-centred interviews present a more detailed picture: The theoretical part of the workshop, in which the existing evidence on the development and prevention of joint contractures was conveyed, was found to be not really instructive, on the other hand the practical elements of the workshop were judged as particularly relevant for daily care.
Facilitator (F3, C2) about the theoretical part of the workshop:
I had thought that maybe I would learn something new, [...] but that was not the case.
Facilitator (F1, C1) about the practical part of the workshop:
What I liked very much was that someone from the medical supply store was there. I thought it was really good that he had said something too.
The information session was conducted in all clusters according to protocol. A total of 136 participants from seven nursing homes (intervention group n=61; control group n=75) attended the information session; 102 participants (range: 5 to 16 participants per nursing home) completed a questionnaire (response rate: 75%). Out of these 102 attendants, the proportion of nursing staff, residents, and relatives varied widely between the clusters (Table 3). Overall, the quality of the information session was rated with 1.9 points (SD 0.76; range: 1 to 4 points), indicating a good acceptance of the session. The statement by a relative points out why in some nursing homes external participants rarely receive information about the events taking place in the nursing home.
Relative (R2, C3) about the poster with the announcement for the information session:
[…] there's a bulletin board a little further back in the hall, but there are a thousand notes. I don´t really take notice of it.
From the perspective of the facilitators, the session should have reached more nurses.
Facilitator (F13, C4) about the participation of nurses in the information session:
There [should have been] many more employees, perhaps this should have taken place at a different time.
Regardless of their participation in the information session, it became apparent that the content of the session was not detailed enough for the nurses. In the problem-centred interviews, some facilitators therefore suggested a short training session for all the nurses.
Facilitator (F12, C4) about the training of nursing staff:
[...] the head nurse could already decide that [...] I can indeed explain what we have discussed - what the purpose of the intervention is - but to conduct a compulsory training session is a different matter [...]. For one or two hours.
Peer-mentoring (peer-mentor visit,peer-mentoring by telephone,supportive material) was offered to all the nursing homes. Due to sick leave and vacation occurrences, four out of 14 facilitators were unable to participate during the peer-mentor visit. Overall, the peer-mentor visit was highlighted by the facilitators as a useful introduction to implementing PECAN.
Facilitator (F11, C4) about the peer-mentor visit:
It was especially interesting [...] at that time we introduced our residents, you [the researchers] also got to know our residents. That was really, really great.
During the visit the facilitators used a structured assessment tool to review organisational procedures and to develop tailored action plans to implement PECAN into their nursing home. In addition, case conferences were conducted at each visit, and individual care plans were developed for two residents to improve their participation. Support was given by the peer-mentor (all clusters) and an external peer expert (cluster 1, 2 and 4).
The action plans were realised with support of the peer-mentor during the following weeks. In total, 16 counselling interviews were conducted, with strong variation between clusters (between one and seven counselling interviews per nursing home), and facilitators (6 of 14 facilitators received counselling). The mean interview duration was 48 minutes with a range from 10 to 85 minutes (Table 3).
The main counselling topics were individual residents’ care, therapeutic care, use of technical and medical aids, interprofessional collaboration, collaboration with relatives, organisational needs, and implementation activities. The number of counselling interviews is associated with the different methods of both peer-mentors (the first peer-mentor was responsible for cluster 1 and 2; the second peer-mentor was responsible for cluster 3 and 4). Whereas the first peer-mentor imparted a mandatory procedure with fixed appointments right from the start and structured counselling based on specific objectives, the second peer-mentor imparted an optional approach and invited the facilitators to initiate contact themselves whenever counselling was needed. The standardised procedure of counselling with routines for communication and regular appointments was emphasised by both facilitators and peer-mentors as being supportive.
Facilitator (F1, C1) about the peer-mentor:
The mentoring by one of the researchers who continually inquired or provided incentives and motivations… it has always been quite good that there was someone else to ask.
What worked well was my commitment to my contacts. [...] I had defined clear communication paths and tools right from the start.
All the nursing homes used the offered supportivematerials, especially leaflets offering information on the PECAN intervention and the study procedure for relatives, therapists and physicians, as well as posters for promoting physical activity. Additional materials were used in accordance with the individual needs of the nursing homes (Table 3). The problem-centred interviews highlighted the impact to provide supplementary materials to support the implementation.
Facilitators (F13, C4):
Yes, your information material was an advantage, we could hang up the posters. Well, someone always took a look at it.
Facilitator (F8, C3):
A special supplement for the documentation is missing.
The facilitators adopted various measures to implement the PECAN intervention in their nursing homes. The analysis of the facilitators’ diaries (n=10 diaries returned out of 14) revealed that the following measures were conducted in all nursing homes: Adaptation of nursing records and care planning, development of an institution-specific guidance for managing joint contractures, inclusion of residents’ participation goals in case conferences with the nursing staff and the interprofessional team, counselling of colleagues and relatives, discussions with superiors, social workers, therapists and physicians, review of technical and medical aids, and environmental adaptations in the residents’ area and the nursing home. The documentation from the peer counselling and the problem-centred interviews provided better information about what was happening in the nursing homes.
For example on the individual level, in cluster 2 the review of medical aids resulted in the necessity to replace a walker with a more suitable one. Another resident in cluster 2, has been using a wheelchair since moving into the nursing home, although the nurses believed he would be still able to walk short distances. Therapists and nurses agreed to encourage the resident to become more involved in transfers and use a walker in his room.
At the organisational level, cluster 1 organised an interprofessional in-house workshop to optimise the provision of medical or technical aids. The workshop was conducted six weeks after the visit in cooperation with the medical supply store. In addition to the nursing staff and the advisor from the medical supply store, external therapists and the peer-mentor took part to support the training. In cluster 4, the facilitators introduced the PECAN intervention to their nursing team, using the posters and material sets for nursing team training in team meetings, and integrated the intervention in the daily handovers and case conferences.
Attitude and behaviour of nurses
The response of nursing staff to the PECAN intervention after six months is presented in Table 5.
All in all, some of the nurses disagreed (“strongly disagree” and “disagree”) that they felt well informed about PECAN (13/45, 29%), that comprehensive supportive materials were provided (13/45, 29%) and that the facilitators provided counselling whenever it was needed (12/45, 27%). After six months, the overall satisfaction of the nurses (“extremely” and “very satisfied”) with the implementation of PECAN varied strongly between the nursing homes (cluster-variation between 8% and 100%). Particularly in cluster 2, the majority of the nurses felt poorly informed about the PECAN intervention (11/12, 92%) and were dissatisfied with the implementation (5/8, 42%). The interview with the peer-mentor revealed that especially in cluster 2 the facilitators had no support from the nursing home director, which made it impossible for them to realise their role and to involve the nursing staff in initiating changes. In contrast, a facilitator from cluster 3 describes his role as being only supportive to counselling colleagues and instigating changes.
Peer-Mentor (P1) about cluster 2:
[...] it was not at all possible […] to realise the role as facilitator, i.e. the facilitator had the task after the training [...] of passing on the [contents of the intervention] to the colleagues. This was not successful at all in the larger institution. The support of the nursing home director was lacking.
Facilitator (F8, C3):
In the role [as facilitator] I was able to assert myself better. I could say "Come, let's go to the resident and then you show me how you do it".
To identify changes in daily routines due to the PECAN intervention, the nurses in the intervention group as well as in the control group were asked to rate statements towards organisational aspects that contribute to the residents’ participation (Additional file 1; Table A2). For example, in the intervention group, two thirds of the nurses (30/45, 67%) agreed (“strongly agree” and “agree”) with the statement “We often discuss how to improve the care of residents with joint contractures to enable them to participate in social life in the best possible way” at the 6-month follow-up, while less than half of the nurses agreed to this statement at baseline (22/51, 43%) or at the 6-month follow-up in the control group (17/36, 47%).
Enablers and barriers at the nursing home level
Enablers and barriers of implementation at the nursing home level are summarised in Table 6.
Implementation at the nursing home level is influenced by the personal characteristics of the different stakeholders and by the organisational and structural conditions of the nursing homes. Moreover, there are differences between the included clusters and between the perceptions of the stakeholders. For example, the facilitators experienced the social relationship, which includes the open-mindedness of staff towards the PECAN intervention, in different ways.
Facilitator (F1, C1):
It’s hard... to really convince these die-hard nurses to actively participate, to implement, to think, to observe. That is difficult [...], and they must really want it.
Facilitator (F12, C4):
Now something is happening here and I felt it was positive that we were practically involved. Half [of the nursing staff] could also have said “Oh, I don't feel like it” [...] or “I'm not interested in that here”.
As a fundamental precondition for a successful implementation, the clear commitment of the entire nursing home is required. This covers an active leadership in supporting the changes, open-mindedness to the changes, and clear responsibilities. These quotes from two facilitators illustrate how commitment can be experienced and, in contrast, how implementation stagnates if there is no commitment by the nursing home.
Facilitator (F9, C4):
We were always exempted from work for the meetings. For discussions, we got extra time. [...]It was a very, very close collaboration.
Facilitator (F6, C3)
I missed the togetherness [...]. I had talked to the head nurse after our workshop [...], but I had the impression ‘yes, that's nice you were here’ [...]. I missed the commitment and the interest.
Moreover, a successful implementation is motivated by respecting the expertise of the different stakeholders, as emphasized in the following quote.
Facilitator (F1, C1):
And I also have to say, the whole solidarity between us all, nurses, physical therapists, physicians, occupational therapists, this is now a really good collaboration, it works, you complement each other, you get tips.
A lack of impact on organisational conditions and routines was identified as a major barrier for the implementation. This includes unclear responsibilities and a lack of interprofessional collaboration which was impeded by the strict separation of working areas and the lack of an established culture of change. The subsequent quote by a therapist addresses the problem of the documentation.
Therapist (T3, C2):
[...] we have a documentation obligation as therapists. However, the documentation is run via our practice and not the nursing home. Well, I don't have to explain what I did in the nursing home, but that's normal.
A barrier that was reported as important across all clusters and from different stakeholders was a lack of time and staff competence, as illustrated by the subsequent quotes:
Social worker (S2, C2):
Well, it’s not like I’m closed off to communication, for example. But very often it’s a time problem. That you don’t take enough time to share information or to communicate.
Facilitator (F6, C3)
The major problem is of course the staff shortage, this is still known in many nursing homes [...] the time of course [...] whether management or staff, everyone has to do his work, is a bit stressed [...]