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Clinical Trial
. 2024 Feb 1;64(2):gnad064.
doi: 10.1093/geront/gnad064.

Building a Program Theory of Implementation Using Process Evaluation of a Complex Quality Improvement Trial in Nursing Homes

Liane R Ginsburg  1 , Adam Easterbrook  2 , Ariane Massie  3 , Whitney Berta  4 , Malcolm Doupe  5 , Matthias Hoben  1 , Peter Norton  6 , Colin Reid  7 , Yuting Song  8 , Adrian Wagg  9 , Carole Estabrooks  8
Affiliations
Clinical Trial

Building a Program Theory of Implementation Using Process Evaluation of a Complex Quality Improvement Trial in Nursing Homes

Liane R Ginsburg et al. Gerontologist. .

Abstract

Background and objectives: Significant quality problems exist in long-term care (LTC). Interventions to improve care are complex and often have limited success. Implementation remains a black box. We developed a program theory explaining how implementation of a complex intervention occurs in LTC settings-examining mechanisms of impact, effects of context on implementation, and implementation outcomes such as fidelity.

Research design and methods: Concurrent process evaluation of Safer Care for Older Persons in residential Environments (SCOPE)-a frontline worker (care aide) led improvement trial in 31 Canadian LTC homes. Using a mixed-methods exploratory sequential design, qualitative data were analyzed using grounded theory to develop a conceptual model illustrating how teams implemented the intervention and how it produced change. Quantitative analyses (mixed-effects regression) tested aspects of the program theory.

Results: Implementation fidelity was moderate. Implementation is facilitated by (a) care aide engagement with core intervention components; (b) supportive leadership (internal facilitation) to create positive team dynamics and help negotiate competing workplace priorities; (c) shifts in care aide role perceptions and power differentials. Mixed-effects model results suggest intervention acceptability, perceived intervention benefits, and leadership support predict implementation fidelity. When leadership support is high, fidelity is high regardless of intervention acceptability or perceived benefits.

Discussion and implications: Our program theory addresses important knowledge gaps regarding implementation of complex interventions in nursing homes. Results can guide scaling of complex interventions and future research.

Keywords: Evaluation; Intervention/trial methods; Long-term care.

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Conflict of interest statement

None.

Figures

Figure 1.
Figure 1.
Schematic of how teams implement the SCOPE intervention. CA = care aide; QA = quality advisor; QI = quality improvement; SCOPE = Safer Care for Older Persons in residential Environments intervention.
Figure 2.
Figure 2.
Relationship between intervention characteristics and fidelity at different levels of sponsor support. SCOPE = Safer Care for Older Persons in residential Environments intervention.
See this image and copyright information in PMC

References

    1. Alzheimer Society of Canada. (2010). Rising tide: The impact of dementia on Canadian Society. https://alzheimer.ca/sites/default/files/documents/Rising-tide_Alzheimer... (accessed April 13, 2022).
    1. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215. doi:10.1037//0033-295x.84.2.191 - DOI - PubMed
    1. Barnett, M. L., & Grabowski, D. C (2020). Nursing homes are ground zero for COVID-19 pandemic. JAMA Health Forum, 1(3), e200369. doi:10.1001/jamahealthforum.2020.0369 - DOI - PubMed
    1. Barry, T., Brannon, D., & Mor, V. (2005). Nurse aide empowerment strategies and staff stability: Effects on nursing home resident outcomes. Gerontologist, 45(3), 309–317. doi:10.1093/geront/45.3.309 - DOI - PubMed
    1. Bliese, P. (2000). Within-group agreement, non-independence, and reliability: Implications for data aggregation and analysis. In Klein K. J. & Kozlowski S. (Eds.), Multilevel theory, research, and methods in organizations: Foundations, extensions, and new directions (pp. 349–381). Jossey-Bass.

Publication types

Grants and funding