The findings include 1) a pre-post comparison of staff learning needs; staff readiness to change; audit of practice 2) evaluation of the process of implementation through staff survey items and interviews with site champions. Of the 42 nurses and HCAs who completed the post-implementation survey, 31 (74%) attended at least one WBLG session. Findings are presented according to the CFIR framework. Within the CFIR, characteristics of the innovation, the inner setting and the process were most frequently illuminated by the data while the outer setting and characteristics of the individuals received limited attention in the data (influential components of CFIR are highlighted in Fig. 1). This was likely due to the focus of our intervention being site specific and the staff collective rather than individual.
Participants identified an advantage to implementing the intervention compared to their previous practices. In the post-implementation survey, 100% of staff who attended WBLGs indicated that they had high expectations about both the education and implementation of the guidance in dementia care on their ward, however this view was less common (56%) among those who did not attend WBLGs (Tabulation of responses included in Supplementary File 2). Champions reported that the intervention raised awareness of different assessment and management techniques available in each area; it made staff reflect on care and think outside the box; and was valued for its orientation towards person-centred care. Specific tools to aid pain assessment were valued such as the Doloplus 2 Scale for patients with cognitive impairment or communication issues. Champions also highlighted that the guidance provided affirmation for the practices they were already engaging in. One champion identified how the guidance was a good back-up to support their approach to care:
“Some of us have done dementia and palliative care training and had a background in it already so I suppose what it did was to give us the confidence to keep on doing what we were doing and another way of looking at things.” (Champion C, Site 3)
In one site, a champion noted that when the guidance was introduced gradually and observed by staff in practice with one resident initially, this provided support for the guidance and encouraged staff to incorporate it.
“It had gone from focusing on one residents needs to involving the whole process of review of all residents’ medications. I came away saying, okay, this is something we can start to bring to the attention of other ward managers in the area.” (Champion A, Site 1).
Design Quality and Packaging
This intervention included the provision of hard copy guidance documents with integrated fact sheets and assessment tools. Data from post-implementation questionnaires indicated that all staff who attended WBLGs felt that the guidance documents were useful. 70% (7/10) of those who did not have the opportunity to attend a WBLG, also felt the documents were useful, demonstrating reach beyond the WBLGs. Champions mentioned how beneficial it was to have all pertinent information in one document and that this information along with the fact sheets was accessible. However, they noted that the fact sheets had the potential to be lost within the overall guidance document without drawing attention to them as part of the WBLGs. The WBLGs were valued as a way of highlighting critical aspects of the guidance.
“It is great to have information in a book and people know where to get it, but the fact sheets can get lost in the pack. This process (WBLGs) brings them to the fore.” (Champion A, Site 1)
Networks and Communications
Site profiles indicated that allied health professionals from different disciplines visited care settings with varying frequency. A lack of support from other allied health professionals was commonly reported as a barrier to implementation (Table 2). For example, support for medication review requires input of doctors and pharmacists. To a lesser extent, champions also highlighted the influence of support from other allied professionals but did not frame this as a barrier.
The implementation climate captures shared openness to change and is reflected in both the qualitative and quantitative data. The qualitative data suggested that champions welcomed education in dementia palliative care: “Education is always important to keep up to date” (Champion B, Site 2). The support and engagement of other colleagues in the process was a prevalent facilitator of implementation identified in staff surveys (n = 9) while teamwork was also identified as a facilitator (n = 3) (Table 2).
The VOCALISE scale (29) and subscales also shed light on factors affecting implementation within the inner setting (Table 3). Pre and post, participants had negative results for the de-motivation subscale. This subscale refers to lack of motivation experienced by staff when colleagues are not engaging with the intervention. Overall, there were no statistically significant differences from pre-implementation to post-implementation. However, there was a trend indicating reduced demotivation in those who attended the WBLG in post-implementation data (Mdn = 22.00) compared with the pre-implementation (Mdn = 19.50), U = 497.00, p = 0.07 suggesting that engagement in the implementation strategy through a PAR process may have positively impacted on demotivation.
Readiness for Implementation
Leadership and support from ward managers/CNMs were amongst the most common facilitators of implementation identified by staff. Following implementation, almost all those who attended the WBLGs felt that attendance was supported by management (100%) and agreed that the implementation of guidance received managerial support (97%). For staff that did not attend WBLG’s, the percentage expressing the same views was lower 56% (5/9) and 60% (6/10), respectively. This suggests that a small number of staff perceived that there was a lack of management support for implementation which may have influenced their participation.
The availability of resources also influenced the implementation strategy and intervention. In terms of access to knowledge and information, when surveyed, 97% of staff who attended at least one WBLG agreed that enough education sessions were provided. Unsurprisingly, only 40% (4/10) of those who were unable to attend WBLGs agreed with that statement. A small number of staff (n = 2) surveyed post-implementation reported lack of knowledge as a barrier to guidance implementation and qualitative data indicated that time to attend the WBLGs was a challenge. Champions discussed the challenge and stress for staff of being needed ‘on the floor’ when residents required high level support.
“Not all staff were able to attend and those that did, felt the stress of catching up on our work once back on the ward” (nurse, survey comment).
From a champion perspective, inconsistencies in attendance across WBLG sessions also created difficulty with continuity of learning. In the post-implementation survey, changing staff and lack of continuity of care were reported as barriers to implementation (Table 2).
“It worked well I have to say but every time there were different staff going up to the information sessions so that would be an issue.” (Champion B, Site 2)
In addition, the powerlessness subscale of the VOCALISE instrument includes factors that influence staff readiness for change including inadequate staffing, time available for implementing changes, and ease of making changes. Our results show participants as ambivalent in relation to powerlessness pre and post-implementation (Table 3) suggesting conflicted views on their power to implement change. The lack of staff (n = 8) and time (n = 7) were commonly identified barriers to implementation.
While it was noted that limited staff availability affected continuity of the WBLGs, it is not required that the same staff attend all the sessions in the WBLG facilitation process. Information and learning can be disseminated amongst staff via other communication opportunities such as handover. In support of dissemination, 100% of staff who attended WBLGs reported that they had shared the knowledge gained with other colleagues. Additionally, 73% (8/11) of those who did not attend WBLGs, had accessed the guidance and the same number expressed confidence in using the guidance. Overall, the number of HCAs and nurses reporting any learning needs relating to the guidance documents decreased (x² = 6.28, p < 0.05) from pre-implementation (n = 36, 61%) to post-implementation (n = 12, 34%).
Aside from the individual characteristic of self-efficacy, the data does not illuminate individual characteristics as influencing implementation. Both pre and post-implementation, participants scored positively on the confidence subscale which may contribute to self-efficacy to implement the intervention (See VOCALISE results in Table 3).
There were some suggestions from both champion interviews and staff surveys that intervention planning could have been improved to take cognisance of issues with staff resources and attendance at WBLGs. Some reported a lack of awareness of WBLG sessions; challenges in freeing staff to attend the groups; and challenges for staff on night duty to attend daytime sessions. Champions suggested enhanced communication, to ensure that all staff are made aware of the existence and purpose of WBLG s and a greater involvement of nursing directors/high level management to help address staff cover and attendance.
The champions’ account of implementation suggested fidelity to the intended implementation strategy through WBLGs. The external change agents, that is the WBLG facilitators, were positively evaluated. All staff who attended the WBLGs reported satisfaction with the facilitators’ delivery of the education. Staff perceived the facilitators as being enthusiastic and experienced in their fields. Moreover, staff and champions valued how the facilitators engaged them in creative reflection and active thinking about the practical implementation of the guidance in the context of their ward.
“I thought it was very interesting. It was great the way that it was done. I thought that the two facilitators on the day for me were good and all the staff would have felt the same. They engaged us well and they got us thinking and I liked the process – I enjoyed it actually.” (Champion D, Site 3)
There was an eagerness for facilitators to return to provide further support. The follow up process was perceived as useful.
“From the presentation point of view, everything was made very clear and followed up with action plans. We used these and they followed up with us to see how we got on.” (Champion B, Site 2)
The participatory process was valued as it encouraged of the engagement of all staff and supported each individual's input. As described by Champion A (Site 1), diversity in attendance “opened up huge areas and actually the awareness too that other staff have insights as well”. However, other health professionals such as GPs were less engaged and this was suggested as a useful target for future projects. The use of images and ‘evoke’ cards with the groups were valued as a means of encouraging full engagement:
“With the cards everybody had to become involved and everybody had to engage. It was good for encouraging feedback really and there was a couple of varied responses that might not have happened without that creativity.” (Champion C, Site 3)
Interviews with champions indicated that the guidance was implemented. This often took the process of initial trialling of an assessment tool with one or more residents for example and then expansion to others. However, there was also an acknowledgement that not all staff had adopted new techniques as part of practice. The project was seen as a good starting point but there was a journey ahead in terms of adopting the guidance consistently in practice. In the case of guidance on hydration and nutrition, staff were reported to be already engaging in most of the guidance recommendations. Nevertheless, the intervention provided affirmation of practice, and enhanced awareness.
Data from an audit of the records at each site indicated increased compliance with processes recommended by the guidance both pre and post-implementation (Table 4). Some items not frequently documented pre-implementation were documented to a greater extent post-implementation, such as discussions with family and residents concerning medications.
Reflecting and Evaluating
Champions noted that the intervention had provided an opportunity for direct reflection on practices through the WBLGs. However, the importance of providing feedback from the study findings to staff was stressed to encourage further engagement with the guidance.
“I’d like to be able to relay that feedback to the staff and make it available to them. Just to look at your comments and to have a ‘two-way’ connection between the research results to see the staff reaction.” (Champion C, Site 3)