Implementation of a complex intervention to reduce hospitalizations from nursing homes: a mixed-method evaluation of implementation processes and outcomes

Abstract

Background | objectiveTo evaluate the implementation of three intervention elements to reduce hospitalizations in nursing home residents.DesignConvergent mixed-method design within a hybrid type-2 effectiveness-implementation study.SettingEleven nursing homes in the German-speaking region of Switzerland.ParticipantsQuantitative data were collected from 573 care workers; qualitative data were collected from 108 care workers and the leadership from 11 nursing homes.InterventionThree intervention elements targeting care workers were implemented to reduce unplanned hospitalizations: (1) the STOP&WATCH instrument for early recognition of changes in resident condition; (2) the ISBAR instrument for structured communication; and (3) specially-trained INTERCARE nurses providing on-site geriatric support. Multifaceted implementation strategies focusing both on the overall nursing home organization and on the care workers were used.MethodsThe quantitative part comprised surveys of care workers six- and twelve-months post-intervention. The intervention’s acceptability, feasibility and uptake were assessed using validated and self-developed scales.Qualitative data were collected in 22 focus groups with care workers, then analyzed using thematic analysis methodology. Data on implementation processes were collected during implementation meetings with nursing home leadership and were analyzed via content analysis. Findings were integrated using a complementary approach.ResultsThe ISBAR instrument and the INTERCARE nurse role were considered acceptable, feasible, and taken up by > 70% of care workers. The STOP&WATCH instrument showed the lowest acceptance (mean: 68%), ranging from 24 to 100% across eleven nursing homes. A combination of factors, including the amount of information received, the amount of support provided in daily practice, the users’ perceived ease of using the intervention and its adaptations, and the intervention’s usefulness, appeared to influence the implementation’s success. Two exemplary nursing homes illustrated context-specific implementation processes that serve as either barriers or facilitators to implementation.ConclusionsOur findings suggest that, alongside the provision of information shortly before intervention start, constant daily support is crucial for implementation success. Ideally, this support is provided by designated and trained individuals who oversee implementation at the organizational and unit levels. Leaders who seek to implement interventions in nursing homes should consider their complexity and their consequences for workflow to optimize implementation processes accordingly.Trial registrationThis study was registered at clinicaltrials.gov (NCT03590470) on the 18/06/2018.