Resistance to change is an issue occurring in all organizations when change is required. Many people working in health care are not interested in change or feel the need to change. Management in all three researched facilities described that they tried to diminish this resistance by communicating the usefulness of this new assessment system and involving staff by taking courses in the use of the interRAI-LTCF. They all feel that there is no longer any resistance now. The manager of residential care home 1 mentioned that during the introduction of the interRAI-LTCF assessment a lot of changes in management and financial support were on going in the organization. This was the main reason for some aversion to this ‘new management thing’. In order to deliver a better quality of care availability of sufficient staff and resources as computer equipment is obvious . Based on the opinions of staff different signals were found. In RH 1 nursing assistants feel that there are in general not enough people working in the organization and that there is not enough staff that can fill in the interRAI-LTCF in the appropriate manner. In RH 2 and 3 sufficient staff is available to fill in the interRAI-LTCF according to the nursing assistants. Time is, as comes clear, another important resource. In all residential care homes four hours a week are scheduled to fill in the interRAI-LTCF. According to the managers more time could be needed for appropriate use of the interRAI-LTCF. In RH 2 and 3 staff mentioned that there is sufficient time available to work with the interRAI-LTCF, but staff in RH 1 felt that there is not enough time available.
Management and staff of all three facilities agree that the computer equipment is not sufficient to work with the interRAI-LTCF. The manager of RH 3 brought up the suggestion to use laptops in the future. The interRAI-LTCF can be filled in together with the resident and family in the residents’ apartment. Doing so involves residents and family in the care process. Teamwork can be seen as inter and intra organizational cooperation between organizations and people. The output of the interRAI-LTCF on residents will lead to shared decision making and involves members of the multidisciplinary team in the steps to be taken in the individual care process. Complex care needs will be discussed in the Multidisciplinary Meeting (MM). All interviewee’s feel that using the interRAI-LTCF improves teamwork by better information, enables better structuring of MM’s and shared decisions on the care plan. The culture of the facilities has changed by using the interRAI-LTCF. In most health care organizations there is an unofficial hierarchy where nurses, or nurse assistants will and cannot easily tell their opinion to a physician . With the use of the output of interRAI-LTCF as basic information guiding the care process and structuring the MM all care givers need to work together to create the best possible care for the resident. Opinions of nurses and nurse assistants are appreciated and taken into account. As family physicians mention that residents in residential care homes need more complex care and that the availability of skilled staff is under pressure empowering of the nursing assistants will be important. Training and empowerment of nursing assistants together with monitoring using the interRAI-LTCF were likely to be the most important ingredients for improvement of the quality of care . Statement of RH 2 manager: ‘RAI has created a deeper insight in the resident’s needs and wishes.
Comparison with literature
There is to our knowledge no literature on implementation of a care model using interRAI-LTCF in residential care homes. In several studies about staff satisfaction using a Resident Assessment Instrument version in the US [8, 13] was found that more than 64% of nursing home directors felt that it is worth time and effort spent by staff. They also felt that the quality of care planning and the assessment of patients improved in comparison to other instruments they were using before.
The opinion of management in our study on improvement of quality of care by using the interRAI-LTCF is a full outspoken yes. This is in line with the results of other studies [7, 18]. Patient assessment by means of the interRAI-LTCF provides more accurate information about the needs and wishes of patients than single assessment instruments. Client- tailored care plans can be formulated on the basis of this detailed multiple domain information. These client- tailored care plans can diminish the gap between patient’s needs and expectations of the care they need and the actual care provided. Consequently, this will lead to improved quality of care . Staff and management in our study also mentioned a better understanding of the needs and wishes of the residents. In another study  the interRAI-LTCF was described by 73% of the interviewed nursing assistants as a tool able to give a ’whole picture ‘of the resident, allowing the nursing assistants to ’know the resident better’, and a practical instrument for providing better care to residents. Like Bernabei we also found resistance likely due to the ignorance of the rationale of the multidimensional assessments by people working in geriatric care. Various professionals like the geriatrician and psychotherapist and some nursing assistants had a hard time accepting the rationale of such an assessment tool and system. Other impeding factors like staffing problems and inadequate equipment were also found by Holtkamp (2003) and Achterberg (2004) [17, 19].
Strengths and limitations
We were able to achieve participation from a large and extremely difficult study population and implemented the Multidisciplinary Integrated Care model in a single care organization having the possibility of uniform implementation. This contributed greatly to the internal validity of the study results. The introduction phase took 3 months including training of the nurse assistants in using interRAI-LTCF. After the 6 month period of the main study the care model including working with interRAI-LTCF was implemented in the control homes within 3 months. A project manager of the care organization provided in the introduction as well as in the maintenance phase coaching on the job of the nurse-assistants and the managers.
There are some limitations. The cluster randomization produced an imbalance between the intervention and control homes in the number of participating residents and in some of the functional characteristics of the residents at baseline. Although we adjusted for the imbalance in functional characteristics, imbalance in the number of participating residents may have led to underpowered results. Variation across the intervention homes in the application of the complete protocol (3%–66%) was another limitation of the main study. This variation can be explained by financial and administrative issues during the study period of the main study. The financial obligations for residential care homes resulting from a new national funding system for residential care of elderly people caused uncertainty about job continuation, high turn over of managers, and new priorities of the homes in our study. Only 55.2% percent of the residents in the intervention homes were assessed with the Long Term Care Facility version during the study period of 6 months. This was less than we aimed for and was partly due to implementation delay . For example, one intervention home actually started RAI assessments after 6 months because the house manager was on sick leave.
For the first research question the investigated sample was limited due to lack of time, illness and vacation of managers and nursing assistants. In addition, the interviews used in the initial phase were tested on construct and expert validity but not on criterion validity and reproducibility.
For the second research question an important limitation was the relatively small sample which was due to the exploratory and in- depth nature of the interviews. Another possible limitation is that this study was conducted in three residential care homes all belonging to the same care organization. Because of the small sample and the exploratory nature of the research no real generalization can be made.