High Staff Turnover Research Articles

Improving Staff Workflow in Urology Procedure Clinic Using the Model for Improvement

To maximize procedure volume and minimize workflow inefficiency in our urological procedure clinic, we hypothesized that for staff (nurses/medical assistants) and patient teams, team workflow duration (TWD) (the time required to complete team duties for a single appointment) could be reduced by 50% with a targeted workflow intervention developed using the Model for Improvement and Plan-Do-Study-Act cycles. Workflow inefficiency leads to wasted time and workplace dissatisfaction, resulting in lost revenue due to low procedure volume and high staff turnover. A baseline time study was performed to measure TWD for clinical teams, including the front desk, physician, staff, and patient teams. Implementation of previously identified interventions was also recorded. A workflow intervention was developed in which staff duties were split among two roles: staffer and triager. TWD and intervention implementation were remeasured over six Plan-Do-Study-Act cycles. Semistructured interviews were conducted as a balance measure to assess impact on staff workflow and wellness. Our workflow intervention resulted in a 44% and 42% reduction in staff and patient TWD, saving nearly 17minutes per appointment on average. Thematic analysis revealed that time saved could be best used to protect lunch breaks and allow time to complete nonclinical duties such as patient calls, which had previously been performed after-hours. Introduction of staffer and triager roles to staff workflow increased clinic efficiency by reducing workflow and procedure appointment duration. Time saved was used to increase procedure volume while also supporting staff wellness.

Work Experiences of the Interdisciplinary Dialysis Workforce in the United States: A Cross-Sectional Survey

Introduction: Suboptimal dialysis care may be in part due to staff issues such as job dissatisfaction, burnout, work overload, high staff turnover, and inconsistent training. Here, we leveraged data collected in a recent national survey to provide an initial, comprehensive description of current work experiences of US dialysis care providers. Methods: We conducted a cross-sectional survey of 1,240 active US dialysis clinic staff members (physicians, advanced practice providers, nurse managers/clinic coordinators, nurses, social workers, dietitians, and patient care technicians), who were recruited via emails to society membership lists. Respondents were asked about a wide variety of work experiences, including job satisfaction, professional fulfillment, and burnout (Stanford Professional Fulfillment Index), work culture, experiences of hostility and violence, and self-reported medical errors. Responses were summarized overall and compared by clinic role. Results: Most of the survey respondents, representing all 50 US states, were aged 35–49 years (58.3%) or ≥50 years (23.5%), female (60.7%), and white (59.8%; 23.1% black, and 10.0% Asian); 82.1% had been in their current role for at least 1 year. Most US dialysis staff responding to our survey reported being generally satisfied with their jobs (mean rating of 7.9 on 0–10 scale), but only 54.4% met criteria for professional fulfillment, and 32.8% met criteria for burnout, driven by high scores in the work exhaustion domain. Related issues, including high workloads, lack of respect (including experiences of violence and hostility), lack of autonomy, and suboptimal patient environments (in terms of both safety and patient centeredness), were commonly reported among dialysis care providers, although their prevalence often differed by provider type. Conclusion: Our results suggest that the dialysis workforce may be at a critical point. Preventing further staff burnout, which could lead to even greater staffing shortages and worse working conditions among those who continue to provide dialysis care, is essential.

Unpacking the Effects of High Staff Turnover in Zimbabwean Government Hospitals

Economic factors in the international scene have attracted trained and qualified health personnel in other countries. The mass exodus has been happening at an alarming rate, resulting in disadvantaged countries losing effective hospital staff. Staff turnover has been witnessed in Government administered hospitals in Zimbabwe. Both low and high staff turnover has proven to affect the healthcare system. This is evident in the poor health service that is being delivered after qualified and experienced doctors, nurses and other related personnel have left their work places in search of better opportunities and greener pastures. The study gathered findings from related literature and distributed questionnaires around selected hospitals in an attempt to evaluate and assess the effects of high staff turnover in Zimbabwean hospitals. Thus, a survey on the results of being short staffed due voluntary hospital staff turnover has shown the negative effects of staff turnover in Zimbabwean hospitals. The study included four government hospitals (GH) as case studies, these are; Chivhu, Sadza, Kotwa and Marondera Hospitals. The study reviewed that 95% of the respondents indicated that there was a record of staff turnover at their respective hospitals. The research results showed that nurses constituted the most staff members leaving government hospitals, making up 29.49% of the total turnover in the four GH involved in the study. The destination for those nurses and other medical practitioners was regarded as ‘g mainly regarded as ‘greener pastures’ in the United Kingdome effects of staff turnover was the shortage of qualified and experienced staff members in hospitals in Zimbabwe which affected the quality-of-service delivery. This article gives in detail the objectives, results and recommendations for the topic in question.

A survival analysis approach to determine factors associated with non-retention of newly hired health workers in Iran

Background and aimOne of the main tasks of the healthcare human resource management is to maintain and retain professional staff. The high level turnover of professional staff may reduce the quality of healthcare service delivery. Therefore, this study investigated the factors associated with the turnover of the newly recruited healthcare professionals using survival analysis method in Iran.Materials and methodsThis historical cohort analysis comprised 6811 employees who began working at Mashhad University of Medical Sciences between 2005 and 2020. Employees recruited at any of the university’s units between the years 2005 to 2019 were included. We used appropriate descriptive indices and Log-rank test and the Cox proportional-hazards model to assess the staff turnover. A significance level of 0.05 was used for all tests.ResultsThe findings of the survival analysis showed that the probability of turnover in one year, two years, and five years of employment were 0.12, 0.16, and 0.27. Based on the findings of the Log-rank test, the probability of turnover in entire of the study period was not statistically different between male and female (p = 0.573), and likewise between employees with healthcare occupations and non-healthcare occupations (p = 0.351). Employees whose current workplace and birthplace were not similar had a significantly higher probability of turnover (p < 0.001). Accordingly, the Cox regression result showed, the risk of turnover for the singles was 1.22 times higher than the married. For the Ph.D degree was 3.23 times higher compared to those with a diploma or an associate degree, and for a bachelor’s or master’s degree was 2.06 times more likely to change their workplace than those with a diploma or an associate degree.ConclusionPolicies promoting the recruitment of native-born professionals, given priority to the married candidates than single ones, and/or recurring candidates to pledge to stay in the locality of recruitment site can increase the staff retention and reduce the costs of staff turnover including re-hiring, initial and on-the-job training, accommodation, and other extra living consumptions away from home and family.

Facial recognition lock technology for social care settings: A qualitative evaluation of implementation of facial recognition locks at two residential care sites.

There is limited literature on security and access for social care settings despite policy highlighting importance, and no published research exploring facial recognition lock technology (FRLT) for potential improvements. This study explored FRLT device implementation, use, barriers and benefits. One residential care home with 43 older adults and 68 staff members (Site A), and one supported living facility caring for six individuals with mental health issues with 18 staff members (Site B) were provided with FRLT for six months. Nine pre-implementation staff interviews explored existing access and security perceptions. Ten post-implementation staff interviews and one staff focus group were conducted; all were analysed using content analysis to understand, alongside process mapping, the use and impact of the FRLT. Interview participants included site care staff and other visiting healthcare professionals. We additionally report feedback from the technology developers to demonstrate impact of industry-academia collaboration. Pre-implementation interviews highlighted issues with current pin-pad or lock-box systems, including; code sharing; code visibility, ineffective code changes, security issues following high staff turnover, lack of efficiency for visitors including NHS staff and lack of infection control suggesting requirement for innovation and improvement. Pre-implementation interviews showed openness and interest in FRLT, although initial queries were raised around cost effectiveness and staff skills. Following implementation, good levels of adoption were achieved with 72% and 100% (49/68 and 18/18) of staff members uploading their face at the two sites, and 100% of residents at Site B using the system (6/6). Additionally, Site B made a positive procurement decision and continues to discuss wider rollout. Post implementation interviews suggested FRLT was useful and acceptable for improving security and access. Benefits identified included staff/visitor time saving, enhanced security, team ease of access, resident autonomy and fewer shared touch points. Integration was suggested including with fire alarm systems, staff clocking in/out, and Covid monitoring to improve usefulness. The developers have since responded to feedback with design iterations. We identified concerns on security and access in social care settings, which warrant further exploration and research. FRLT could increase resident autonomy and reduce staff burden, particularly considering frequent multi-agency health and care visits.

Impact of perceived supervisor support and leader-member exchange on employees' intention to leave in public sector museums: A parallel mediation approach.

High staff turnover in certain public sector organizations in Pakistan is a challenging problem, and organizations strive to reduce this issue using different mechanisms. Therefore, this research investigates the parallel mediation impact of perceived organizational support (POS) and organizational citizenship behavior (OCB) on the relationships among perceived supervisor support (PSS), leader-member exchange (LMX), and employee's intention to leave (IL). Data were collected from 482 employees working in public sector museums in Pakistan in three waves. Structural equation modeling (SEM) with a two-step approach was used to evaluate the data. The research found that both POS and OCB mediate the negative relationship between PSS and IL and between LMX and IL in a parallel mediation mechanism. Public sector museums should focus on providing visible supervisory support and develop a healthy work environment where the exchange relationship between supervisors and subordinates strengthens to reduce the possibility of the employee's leave intentions.

Clinical Nurse Specialist and Clinical Nurse Leader Collaboration During the COVID-19 Pandemic.

The aim of this study was to describe an innovative strategy to maintain healthcare worker safety and optimal patient outcomes that was implemented by a healthcare system in the Southeastern United States during the COVID-19 pandemic. During the surges of the COVID-19 pandemic, healthcare systems have struggled with healthcare worker burnout, high staff turnover rates, and redeployment of staff to unfamiliar areas and the uncertainty regarding COVID-19 personal protection and patient care. Clinical nurse specialist/clinical nurse leader teams were created to help ensure healthcare worker safety and optimize patient care outcomes. Healthcare worker safety and desired patient outcomes were maintained. Throughput was expedited for emergency department patients, and there was timely implementation of therapeutic modalities for critically ill patients. Clinical nurse specialist/clinical nurse leader team collaboratively cross-trained staff to ensure their safety and delivery of quality patient care. The team was pivotal in helping safeguard staff from harm while optimizing patient outcomes. Lessons learned will help us in future disasters as well as our daily operations.

Exploring Subordinates' Perceptions and Experiences with Abusive Leaders in Higher Education: A Qualitative Study

Exploring Subordinates' Perceptions and Experiences with Abusive Leaders in Higher Education: A Qualitative Study

Formal Caregivers in Intellectual Disability Facilities

IntroductionCaring for individuals with intellectual disabilities is a passionate, but challenging profession. Whether working in residential homes or in occupational facilities, its staff deals with the ordinary issues of teamwork, but also with these clients behavioral comorbidities. It often includes self-harming and aggression towards others – namely towards the staff itself. This is particularly relevant since a high turnover of staff implies the loss of people who are familiar with the needs and specificities of those clients. The quality of care provided may also be affected.ObjectivesTo investigate whether, or not, formal caregivers are at greater risk of occupational health issues, and what their main determinants are.MethodsResearch in Medline for intellectual disability caregivers. Only the relevant articles, published in English, were considered.ResultsAmong formal caregivers of people with intellectual disabilities, job dissatisfaction and job strain were found to be especially relevant and were associated to the following variables:• Younger workers or those with less professional experience• Personality and individual maladaptive coping strategies• Poor organizational support• Conflicting, ambiguous, or overloaded professional roles• Unclear work tasksThe incidence of Burnout Syndrome was also described as relevant among these workers and was associated not only to aggression towards the worker, but also to the fear of aggression.ConclusionsCaring for people with intellectual disabilities, in a residential or in an occupational context, implies heavy emotional and physical demands and a high prevalence of job dissatisfaction, Job Strain and Burnout Syndrome. In addition to the high risks to the quality of life and health of caregivers, there are consequences for the quality of the care that is provided. For this reason, guaranteeing proper work conditions should be considered part of the Social Institutions main goals. Yet, we lack specific, controlled studies that properly evaluate what measures could indeed help institutions to prevent occupational (and mental) health distress among their staff.Disclosure of InterestNone Declared

Innovative methodology for the development of operational management standards in the hotel business

The object of the study is the role of corporate standards in increasing the effectiveness of service quality management in the hotel sector. The work is aimed at clarifying and expanding the theoretical and methodological provisions of service quality management in the field of hospitality, for which it is necessary to propose a toolkit for the development and implementation of corporate standards, and to develop recommendations for improving the effectiveness of service quality management. In the course of the study, logical approaches to the analysis and development of ways to improve the efficiency of service quality management in the field of hospitality based on corporate standards were used. The work specifies the terminological apparatus, substantiates the role and relevance of corporate standards in hotel service. The goals, tasks, functions and structure of corporate standards are analyzed. The types and distinctive features of corporate standards are established. The prerequisites for the wide application of standards in the field of hospitality are substantiated, in particular, the close connection of the quality of service with the work of the staff, the wide application of the chain form of the organization of the hotel business, the 24-hour mode of operation of hotel enterprises, the high role of operational management and high staff turnover. A toolkit for the development and implementation of corporate standards is proposed. The role of the process approach in the development of service standards is substantiated. A list of service standards for a hotel enterprise is proposed. Recommendations for improving the efficiency of service quality management based on corporate standards in the field of hospitality have been developed. A conclusion was made about the high role and effectiveness of using corporate standards as a service management tool in the field of hospitality. Mechanisms for the introduction and implementation of corporate standards have been developed. It is also important, that the list of standards of operational procedures becomes the basis for evaluating the results of the staff's activities, which plays a role in the motivational programs of the hotel enterprise.

Different Pediatric Acute Care Settings Influence Bronchiolitis Management: A 10-Year Retrospective Study

Bronchiolitis is the main cause of hospitalization in infants. Diagnosis is clinical, and treatment is based on hydration and oxygen therapy. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. This retrospective study aimed to evaluate whether the setting of bronchiolitis care influences diagnostic and therapeutic choices. The management of 3201 infants, referred to our Italian Tertiary Care Center for bronchiolitis between 2010 and 2020, was analyzed by comparing children discharged from the pediatric emergency department (PEDd group) undergoing short-stay observation (SSO group) and hospitalization. Antibiotic use in PEDd, SSO, and ward was 59.3% vs. 51.6% vs. 49.7%, respectively (p < 0.001); inhaled salbutamol was mainly administered in PEDd and during SSO (76.1% and 82.2% vs. 38.3% in ward; p < 0.001); the use of corticosteroids was higher during SSO and hospitalization (59.6% and 49.1% vs. 39.0% in PEDd; p < 0.001); inhaled adrenaline was administered mostly in hospitalized infants (53.5% vs. 2.5% in SSO and 0.2% in PEDd; p < 0.001); chest X-ray use in PEDd, SSO, and ward was 30.3% vs. 49.0% vs. 70.5%, respectively (p < 0.001). In a multivariate analysis, undergoing SSO was found to be an independent risk factor for the use of systemic corticosteroid and salbutamol; being discharged at home was found to be a risk factor for antibiotic prescription; undergoing SSO and hospitalization resulted as independent risk factors for the use of CXR. Our study highlights that different pediatric acute care settings could influence the management of bronchiolitis. Factors influencing practice may include a high turnover of PED medical staff, personal reassurance, and parental pressure.

The Experience of Alcohol and Drug Recovery Service Staff Working with Mothers Who Have Had Their Children Removed

Parenting can be impacted by substance misuse, and children can be at risk of maltreatment, leading to their removal from their mothers. Successful treatment of substance abuse relies on these women gaining effective support from services. Previous research has demonstrated the impact working in this field can have on staff, including high staff turnover, vicarious trauma, and burnout. The present study further explores the experience of staff members working in a Drug and Alcohol Recovery Service in Scotland who work with mothers who have had their children removed. Six interviews with nurses and social care workers were analysed using interpretive phenomenological analysis (IPA). Two superordinate themes were developed from the data: (1) complexity and tension within working relationships and (2) emotional experiences and attempts to resolve them. Participants described the complexity of their roles, including the dual role of supporting mothers while also being involved in the child removal process by providing reports and evidence and how they respond and work with mothers after removal and conflicts with the wider system. They also highlighted their attempts to cope with the emotional impact of being part of this process and the empathy they have with mothers, especially when they are parents themselves, and described the complexities of trying to cope and manage when working in this challenging area. Clinical implications, including training needs and requirements, are discussed.

Gender and the environmental health agenda: A qualitative study of policy, academic, and advocacy perspectives in Peru

IntroductionWomen, especially those living in low-and-middle-income countries experience increased exposure to and impacts of environmental threats. Peru is especially susceptible, with high levels of pollutants associated with extractive industries, and climatic-related disasters exacerbated by climate change. International policies and movements are increasingly calling for a gendered approach to environmental health. We aimed to understand the current Peruvian research, advocacy, and policy landscape at the environment-gender-health nexus. MethodsWe held 18 in-depth semi-structured interviews with key informants from the Peruvian Government, academia, and non-governmental organizations to explore how a gender-sensitive approach and interdisciplinary environmental health collaborations are delivered. We used thematic analysis to compare gender approaches, priorities, and barriers/facilitators to delivering projects within this nexus. ResultsWe remotely interviewed 6 representatives of each sector between July 2020 and March 2021. Interviewees mentioned the detrimental role of weak institutions, multilevel corruption, and the lack of interdisciplinarity and intersectorality across environmental health programs and research. They described several barriers to successful collaboration across organizations and sectors, including funding scandals related to extractive economies, high staff turnover impairing long-term program implementation, and machismo culture in organizations and communities. Women's empowerment was described as important for successful program delivery, especially in female-led associations. Some interviewees emphasized the invisibilization of vulnerable groups, such as girls, teenagers, pregnant women, victims of gender-based violence, and LGBTQI+ people. ConclusionsThese qualitative findings highlight the multiple and inter-related contextual issues faced by environmentally threatened communities in Peru, and how macrostructural barriers contribute to a paucity of sustainable, gender-oriented, environmental health projects.

Job Quality and Job Separation of Direct Care Workers in England.

Most job leavers in the long-term care (LTC) sector in England do not leave the sector, but rather move to other LTC employers. Nevertheless, the high "churn" can have a negative impact on continuity and quality of care, care providers' recruitment and training costs, and the remaining staff workload and motivation. This study aimed to provide quantitative evidence on the drivers of direct care workers' job separation in England, with a focus on job quality. We used yearly data (2016-19) from the Adult Social Care Workforce Data Set, the leading source of LTC workforce data in England, including information on both LTC workers and employers. The analysis considered panel data econometric methods that accounted for unobserved heterogeneity at worker and employer levels. After controlling for observed individual, organizational, and local market characteristics as well as unobserved worker and employer heterogeneity, we found that everything else being equal, wages and employment conditions (i.e., full-time contracts and contracts with guaranteed working hours) significantly reduce job separation. For example, a 10% wage increase from the sample mean would reduce the job separation rate by about 3 percentage points. This wage effect was more than halved (i.e., downward biased) when not accounting for unobserved effects. The persistent high staff turnover in LTC in England highlights the need for finding practical solutions faced by care providers and policy-makers. Our findings showed that improving pay and employment conditions can be the way forward while methodologically stressing the importance of accounting for unobserved variable bias.

Implementation of a pediatric in situ, train-the-trainer simulation program in general emergency departments.

Most children receive emergency care in general emergency departments (EDs). Pediatric resuscitations require specific equipment and weight-based dosing that may be less familiar to general ED healthcare professionals. In situ simulation (ISS) improves teamwork and problem solving, and it may identify latent safety threats. This innovative program brought academic faculty to participating hospitals and taught simulation principles in a small-group environment. This format removed many of the barriers to implementing simulations for general EDs and was intended to teach principles for utilizing simulation to meet unique departmental needs. Using the Consolidated Framework for Implementation Research (CFIR) framework, ED teams at eight hospitals participated in a train-the-trainer program from 2016 to 2020intended to help them implement their own ISSs. Training covered benefits of ISS, use of simulation for identifying latent safety threats, debriefing principles, and potential safety risks of ISS. Faculty also provided on-site mentoring during the implementation phase. We identified factors and barriers that contributed to the successful adoption of an ISS program. Most hospitals continued their ISS program after the study ended. Several themes emerged as pearls and pitfalls to implementing a train-the-trainer program. Successful teams had strong nursing and physician leadership participation, and team members had positive working relationships with early positive feedback which encouraged future ISS implementation. Barriers to simulation included high staff turnover of nurses and physicians as well as social distancing protocols related to infection control. Academic EDs can partner with general EDs to implement a train-the-trainer simulation program. We describe facilitators and barriers to implementing a train-the-trainer ISS program in general EDs to improve emergency care for high-risk, low-frequency events.

The union default: Effects and implications of regulated opting‐out

AbstractA union default would automatically enrol workers in a union with bargaining coverage over their work. Though there would be a right to opt‐out, it would facilitate recruitment and retention of members, especially in sectors with small employers and high staff turnover. Research indicates it would receive majority support and, where available, induce most workers to membership of unions. This study looks at whether two potential features of a union default would influence the intention to remain a union member if defaulted or support for a union default. The first is a mandatory 30‐day waiting period until opt‐out is permitted. The second is a standardised, online process to facilitate opting out.

Local labour market segmentation and migrant workers’ experiences: The case of the hotel industry in Venice

Using Venice as a case study, this article seeks to analyse the experience of migrant workers in the hotel industry through a theoretical engagement with the local labour market segmentation approach. The global hotel industry relies on large numbers of migrant workers, who are often in their first job in the host context, as a solution to the problem of cyclical staff shortages. Previous studies have found that low barriers to entry into the sector and high staff turnover are the underlying reasons for this relationship. They have also shown that the same characteristics that make the hotel sector attractive to migrant workers also lead them to leave the industry shortly after entering it. However, this article reveals significant stability in the careers of migrants employed in Venetian hotels as well as heterogeneity in their individual experiences. Through identifying and analysing the factors underpinning the trajectories of these workers, the article emphasises the importance of local characteristics of production, consumption, institutional and welfare regulation patterns, workers’ social stratifications and strategies of social reproduction in shaping the relation between migrant workers and the local hotel industry.

ENTREPRENUERS’ OPERATIONAL RISKS AND SERVICE STRATEGY: A REVIEW DURING PANDEMIC

The economic impact of the coronavirus disease (COVID-19) is unprecedented and uncertain. No matter the firm, sector, or industry, the pandemic has forced the world to adapt to the current conditions. This paper was focused on the valuation of operational risks and its perceived effects on the service strategy of small and medium businesses in Laguna Province during pandemic. Descriptive type of research and purposive sampling technique were employed with 136 retrieved and treated questionnaires. The self-made questionnaire undertook pilot testing with acceptable to good internal consistency. Data were assessed using tools in statistics such as frequency, rank, mean, weighted mean and anova. The highest weighted mean for the operational risks relative to management is the Untimely management during strategy – setting process in accepting risk. Whereas, in terms of waste identification, High staff turnover, got the highest weighted mean. On the other hand, service strategy was described in moderate performance by the business owners. Management and waste identification in operational risks have significant difference when grouped according to type of service business. Whereas service strategy resulted to have significant differences in business category as to capital, number of employees and type of service business. The findings recommended that Local Government and businesses may create programs that may more greatly assist the industry to fully recover from the effects of the pandemic.

A personhood and citizenship training workshop for care home staff to potentially increase wellbeing of residents with dementia: intervention development and feasibility testing of a cluster randomised controlled trial

BackgroundIn the UK, one third of people with dementia live in residential care homes, a sector where high staff turnover negatively affects continuity of care. To examine the effect of including personhood and citizenship principles in training, interventions need to be robustly tested, with outcomes relevant to residents with dementia.MethodsPhase one intervention development: The training intervention (PERSONABLE) comprised five reflective exercises facilitated by a mental health nurse/researcher. PERSONABLE was informed by four focus groups, and one field exercise, consisting of care home staff and family members. Phase two feasibility testing: Participants were (i) care home residents with dementia and (ii) care home staff working in any role. After baseline measurements, care homes were randomly allocated to (i) staff receiving PERSONABLE training or (ii) training as usual. Feasibility outcomes were the recruitment and attrition of care homes, residents and staff members (measured ten weeks between randomisation and follow-up), the acceptability of the training intervention PERSONABLE, and acceptability of outcome measures. The care home environment was evaluated, at baseline, using the Therapeutic Environment Screening Survey for Residential Care Homes. Measurements conducted at baseline and follow-up were resident wellbeing (Dementia Care Mapping™), staff knowledge of and confidence with personhood and citizenship (Personhood in Dementia Questionnaire and a perceived ability to care visual analogue scale). Inter-rater agreement for Dementia Care Mapping™ was undertaken at follow-up in one intervention and one training as a usual care home.ResultsPhase one: The developed reflective approach to the PERSONABLE exercises appeared to give staff a holistic understanding of residents living with dementia, seeing them as autonomous people rather than reductively as persons with a condition. Phase two: Six care homes, 40 residents and 118 staff were recruited. Four residents were lost to follow-up. Twenty-nine staff in the PERSONABLE arm of the study received the training intervention. In the PERSONABLE arm, 26 staff completed both baseline and follow-up measurements compared to 21 in the training as the usual arm. The most common reason for the loss to follow-up of staff was leaving employment. For the outcome measure Dementia Care Mapping™, the proportion of overall agreement between the two observers was 18.6%. High attrition of staff occurred in those homes undergoing leadership changes.ConclusionWith the right approach, it is possible to achieve good engagement during trial recruitment and intervention delivery of care home managers, staff and residents. Organisational changes are a less controllable aspect of trials but having a visible researcher presence during data collection helps to capitalise the engagement of those staff remaining in employment. Tailored, brief and flexible training interventions encourage staff participation. Simplification of study methods helps promote and retain sufficient staff in a definitive randomised controlled trial. This study found that some components of Dementia Care Mapping™ work effectively as an outcome measure. However, inter-rater reliability was poor, and the practical implementation of the measurement would need a great deal of further refinement to accurately capture the effect of a training intervention if delivered across a large number of clusters. The Dementia Care Mapping™ measurement fidelity issue would be further complicated if using multiple different unacquainted observers.Trial registrationRegistered with the ISRCTN under the title: Does a dementia workshop, delivered to residential care home staff, improve the wellbeing of residents with dementia? Trial identifier: ISRCTN13641553. Registered: 30/05/2017 http://www.isrctn.com/ISRCTN13641553.

Scale-up of a novel vital signs alert device to improve maternity care in Sierra Leone: a mixed methods evaluation of adoption

BackgroundThe CRADLE (Community blood pressure monitoring in Rural Africa: Detection of underLying pre-Eclampsia) Vital Signs Alert device—designed specifically to improve maternity care in low resource settings—had varying impact when trialled in different countries. To better understand the contextual factors that may contribute to this variation, this study retrospectively evaluated the adoption of CRADLE, during scale-up in Sierra Leone.MethodsThis was a mixed methods study. A quantitative indicator of adoption (the proportion of facilities trained per district) was calculated from existing training records, then focus groups were held with ‘CRADLE Champions’ in each district (n = 32), to explore adoption qualitatively. Template Analysis was used to deductively interpret qualitative data, guided by the NASSS (non-adoption, abandonment, scale-up, spread, sustainability) Framework.FindingsSubstantial but non-significant variation was found in the proportion of facilities trained in each district (range 59–90%) [X2 (7, N = 8) = 10.419, p = 0.166]. Qualitative data identified complexity in two NASSS domains that may have contributed to this variation: ‘the technology’ (for example, charging issues, difficulty interpreting device output and concerns about ongoing procurement) and ‘the organisation’ (for example, logistical barriers to implementing training, infighting and high staff turnover). Key strategies mentioned to mitigate against these issues included: transparent communication at all levels; encouraging localised adaptations during implementation (including the involvement of community leaders); and selecting Champions with strong soft skills (particularly conflict resolution and problem solving).ConclusionsComplexity related to the technology and the organisational context were found to influence the adoption of CRADLE in Sierra Leone, with substantial inter-district variation. These findings emphasise the importance of gaining an in-depth understanding of the specific system and context in which a new healthcare technology is being implemented. This study has implications for the ongoing scale-up of CRADLE, and for those implementing or evaluating other health technologies in similar contexts.