Table 2 Triangulation of quantitative and qualitative results: convergence of findings
Core Element | Fidelity Trends from The Quantitative Findings | Moderating Factors for Fidelity from The Qualitative Findings | Triangulation |
|---|---|---|---|
Interprofessional Collaboration | - Moderate fidelity at baseline - Maintained high fidelity during intervention/sustained post-intervention | Context The working practices embedded in NHs prior to the implementation of INTERCARE, such as physician preferences regarding communication and cantonal policies, hindered or facilitated fidelity to this core component. As such, NHs working with responsible physicians had a better basis to develop the interprofessional collaboration. Participant responsiveness NHs enrolled had a communication structure in place prior to the implementation of INTERCARE, which explains moderate fidelity at baseline. NHs made changes in communication structures (such as strengthened reports) at the start of the implementation of INTERCARE which helped develop and strengthen communication between nurses, physicians, and/or therapists and which led to improved collaborations. High fidelity was achieved and sustained after six months after implementation of INTERCARE due to changes in practices which enhanced perception of professional roles, (i.e., nurses felt listened to by physicians and respected). In NHs working with a general practitioner model2, some general practitioners showed resistance to change and collaboration with NH staff was not improved. Quality of delivery NHs described how they optimized the communication process to facilitate communication achieving desired results (i.e., collaborative approach to treatment plans). | Convergence |
INTERCARE Nurse | - Low to high fidelity achieved within the first six months post implementation of INTERCARE - Maintained high fidelity during intervention/ sustained post-intervention | Context INTERCARE nurses worked in different positions with different roles prior to endorsing the INTERCARE role such as working as registered nurse in a team or as unit leader in some NHs. Participant responsiveness The INTERCARE nurse’s role developed rapidly in the NHs with INTERCARE nurses expressing growing self-efficacy and self-confidence, clear responsibilities and boundaries. Although it didn’t hinder reaching high fidelity within the first six months of the study, clarifications as to when the INTERCARE nurse was needed and feeling overwhelmed due to uncertainty of this new role was acknowledged by the INTERCARE nurses. It was clear that the INTERCARE nurse’s role was perceived as a relief for NH staff in challenging situations, and widely accepted by NH staff who responded well to being coached and empowered. Overall, it was acknowledged that there was a need for the INTERCARE nurse’s role. Across the various NHs, the INTERCARE nurses fulfilled a number of outcomes depending on the NH needs, including interval trainings, improving their coaching skills helping NHs work independently and leading expert discussions. Strategies to facilitate implementation NHs introduced the INTERCARE study and INTERCARE nurse’s role as possibilities to better prepare for future challenges. Promoting the INTERCARE nurse’s visibility and part taking in unit activities. Quality of delivery Achieving high fidelity can be explained by high commitment to the INTERCARE role. INTERCARE nurses put effort into being present on units, engaging in unit rounds, combining the INTERCARE role with unit leader role for some of the INTERCARE nurses already working in that role. Physicians invested into training INTERCARE nurses, and having physicians in the background helped the role grow, even though this was not necessarily the case for all NHs and not a minimal requirement for the fidelity measurement. In NHs with an external GP model (i.e., working with external GPs), GPs could not engage in coaching, this didn’t seem to affect reaching high fidelity for those NHs. | Convergence |
Comprehensive Geriatric Assessment | - Moderate fidelity reached at six months and maintained until twelve months. Moderate fidelity decreased to low fidelity post-implementation of INTERCARE | Participant responsiveness Comprehensive geriatric assessment (CGA) was perceived as important by INTERCARE nurses and aspects of this elements were conducted (e.g., clinical assessment with lung auscultation, pain assessment) but not always reviewed and follow-up accordingly, which explained the moderate fidelity during the intervention period. While all NHs assessed with which assessment instruments they worked and where change was needed, the INTERCARE study required them to support care team in integrating the 5 dimensions of CGA in daily practice. This proved challenging concerning financial and psychosocial aspects, which explains that not all minimal requirements could be fulfilled. Strategies to facilitate implementation NHs purposely postponed the introduction of CGA and related tasks to invest in the implementation of other components in view of prioritizing resources and reducing burden. For the elements of CGA which could be implemented, support given on a peer-to-peer basis helped foster putting knowledge into practice (i.e., interpretation of information gained from an assessment). Quality of delivery INTERCARE nurses which demonstrated willingness to implement aspects of CGA reported a lack of “fertile soil” although performing certain clinical tasks (e.g., lung auscultation) prevented some unplanned transfers from occurring. Also, when assessment instruments were used, lack of follow-up was observed, which didn’t improve during the intervention period. | Convergence |
Advance care planning (ACP) | - Moderate fidelity was reached progressively during the intervention period, and continued to increase in the post-intervention period reaching a high degree of fidelity nine months after INTERCARE ended. | Context In most NHs the development and implementation of ACP was slow as time was needed to think and develop clear NH structures and processes needed for the implementation of ACP. Some NHs already had a basis or ACP in practice and INTERCARE helped NHs to strengthen prior practices and facilitate culture change or help NHs to further develop their needs (this was further supported through the COVID-19 pandemic). One NH acknowledged that ACP as a growing theme in the heath sector helped support the introduction of ACP overall. Participant responsiveness Medical engagement for ACP varied across NHs, with ACP being challenging with external general practitioners as opposed to having a responsible physician participating in or overlooking the implementation of ACP in the NH. NHs were able to demonstrate that they had a system in place to anticipate issues occurring during out-of-hours to better address critical situations. Strategies to facilitate implementation NHs developed documents to help facilitate the implementation of ACP (e.g., emergency plan). | Convergence |
Communication tool: Stop & watch | - High fidelity was achieved during the first six months of implementation but decreased continuously thereafter to moderate fidelity. | Context The first NH to start with the implementation reported lacking in information and materials regarding the tools which slowed down their implementation at the start. Participant responsiveness The STOP&WATCH (S&W) tool helped nursing aides to pass on information proudly and NHs reported high staff buy in at the start. Effort was needed to help nursing aides to think for themselves and to not be afraid of using the tool (fear to commit a mistake). This tool was used in different ways, for handover to structure thoughts, but also extended to night teams and activity staff. For some NHs, S&W helped initiate a culture change and follow-up was requested. Although advantages were seen, some barriers were noted, such as difficulty in starting with this tool due to unclarity regarding its usage, misconceptions and how to handle feedback once a tool has been completed. Some INTERCARE nurses and physicians were uncertain as to how to use the STOP&WATCH tool within the nursing team, therefore the minimal requirements were not met. Strategies to facilitate implementation NHs trained champions to help introduce the S&W tool and progressively implemented tools on all units. Displaying the S&W tools enhanced their visibility and helped facilitate implementation. | Convergence |
Communication tool: ISBAR | Participant responsiveness Implementation of the ISBAR tool support decision making and NH staff attitudes toward ISBAR were very positive. They felt valued and able to communicate on an equal level with physicians with professionalism. ISBAR helped with changes in communication practices such as better prepared and structured phone calls between physicians and nurses. Vital signs and better documented and communicated which many physicians missed until the introduction of ISBAR. The utilization of ISBAR was extended to email and unit visits, so that any email correspondence was structured according to the ISBAR tool and contained information in a structured way and unit visits could be prepared in advance. Strategies to facilitate implementation NHs trained champions to help introduce the ISBAR tool and progressively implemented tools on all units. | Convergence | |
Data driven quality improvement | - High fidelity was reached at six months after implementation of INTERCARE and sustained after INTERCARE ended | Participant responsiveness NHs discussed benchmarking reports and quality improvement charts to identify areas for improvement. Some NHs identified specific procedures in place such as regular meetings to work on quality improvement. NHs identified some challenges such as high staff turnover which made it difficult to implement assessments or consistently work on a theme, however this did not seem to affect fidelity to this element. Once main requirement was to use a Plan-Do-Act-Cycle to work on a theme in order to improve and some NHs were not able to use it or mis-used it for other issues not quality related. Strategies to facilitate implementation The NHs were supported by the study leader to better understand how to tackle quality management and NHs demonstrated that different channels (i.e., variety of meetings between different professionals) were available to discuss topics. | Convergence |