Sustaining complex interventions in long-term care: a qualitative study of direct care staff and managers

As complex interventions are tested and adopted within long-term care (LTC), researchers and practitioners must carefully consider the issue of sustainability once the initial intervention or training phase is complete. Sustainability has been defined as the continued use of program components and activities for the continued achievement of desirable program and population outcomes [1]. Sometimes referred to as “routinization” or “institutionalization,” the concept of sustainability incorporates continued benefits, activities, and capacity of the organization to use the intervention effectively [2]. However, the sustainability of complex, evidence-based programs within organizations is challenging [3, 4], with self-reported continuation often less than 50 % [5]. Not surprisingly, a majority (65 %) of implementation science frameworks include sustainability as a key step [6].

While sustainability is a critical consideration for complex interventions, very little literature is available to guide those wishing to promote it. A 2012 systematic review found only 125 articles pertaining to intervention sustainability in healthcare, with none in the LTC setting [2]. We identified only one subsequent article pertaining to the sustainability of complex interventions in LTC; in this study following an 18-month intervention to improve the quality of palliative care in nursing homes in Scotland, a lower level of external support from a nurse specialist (less than half of the intervention level) resulted in maintenance of quality gains in most outcomes. However, outcomes declined substantially in facilities experiencing leadership turnover during the sustainability phase [7]. In the US LTC market, where resources to provide dedicated program staff are scarce and leadership turnover rates can exceed 100 % per year [2], additional data to guide sustainability planning is urgently needed.

We previously reported results from a randomized pilot study showing that an educational intervention, CONNECT, improved measures of staff communication and quality of care, with a trend to decreased facility fall rates [8]. As part of an ongoing randomized controlled trial of CONNECT in a larger sample of facilities, we conducted focus groups of direct care staff (nurse aides, dietary aides, social workers, activity staff, housekeepers, and nurses engaged in daily resident care) and managers (administrators, department managers, staff in education, or supervisory roles) to elicit their views on intervention sustainability. Although the effectiveness of this particular intervention is still under evaluation and consideration of sustainability therefore premature, these focus groups were an opportunity to identify barriers and facilitators to sustaining complex interventions more generally that may inform other LTC researchers and practitioners. Therefore, our goals for this analysis were (1) to obtain staff perceptions of intervention features that optimize or diminish sustainability of a complex intervention and (2) to identify processes, tools, and materials that promote continuation of behavior change interventions such as CONNECT in LTC facilities.

The design of the parent study has been described previously [8, 9]. Briefly, the overall study tests a multicomponent staff education intervention based on complexity science (CONNECT) to promote new connections, information flow, and shared problem-solving about clinical issues among staff in LTC. Staff working in all capacities participated (e.g., dietary aides, nurse aides, housekeepers, nurses, rehabilitation staff, social workers, activity staff, department managers, and administrators). Facilities (n = 16) were randomized to receive either CONNECT for 3 months followed by the Falls Management Program [10] (Agency for Healthcare Quality Research’s quality improvement program) for 3 months or the Falls Management Program alone. The primary outcome is adjusted facility fall rate, with results expected in late 2016.

The CONNECT intervention included multiple components. During two group sessions, staff were introduced to the concept of local interaction strategies (LIS), which are ways of interacting with co-workers, and practiced using them to promote connection, information flow, and problem-solving. The intervention was delivered by trained Bachelors- and Masters-level research staff who did not necessarily have a clinical background. These group sessions used storytelling, role-plays, and interactive games to introduce LIS, learn the rationale for using them, and facilitate practice. Individual staff then met with researchers to create a personalized map showing specific co-workers with whom they wished to share more information about care of their set of residents; they used this map as a guide for completing a self-monitoring tool indicating their use of local interaction strategies over 6 weeks. Over time, staff received individual feedback and mentoring about their reported use of local interaction strategies. In two additional group sessions, department managers, without the administrator or Director of Nursing present, created current and ideal interaction maps for work groups as a whole across the facility and identified ways to improve group connections.

Staff in the eight facilities that were randomized to receive CONNECT participated in the present qualitative study focused on sustainability. Methods for this focus-group study are described in detail below.

Work in healthcare settings other than LTC suggests that the sustainability of complex interventions relates to the innovation itself (fit, adaptability, effectiveness), the context (regulation, culture, structure), processes (e.g., alignment of the intervention and the setting), and the capacity to sustain (e.g., funding, resources, workforce characteristics, and stability) [2]. Within a randomized trial of a behavior change intervention, we used rigorous qualitative methods to elicit staff perceptions of sustainability of behavior change specific to LTC. Our findings confirm that each of these categories is important and provide specific illustrations or suggestions for operationalizing them in LTC. Some suggestions from our participants have been widely used in other settings, for example, using external supports such as clinical champions and orientation materials [17, 18]. However, other insights that relate to specific issues in LTC and require special consideration are discussed below.

Leadership support relating to sustainability requires particular attention in LTC, where historically median job tenure for administrators has been less than 1 year [2]. Ongoing stakeholder buy-in, supervision, and outcome monitoring have been identified as critical components for sustainability by others [5, 19–22]. Indeed, in a study of a national mental health program, the only facility-level factor associated (negatively) with sustainability was leadership turnover [19]. We propose potential strategies to obtain ongoing leadership support in the face of frequent turnover such as leveraging nursing home corporation-level policies (e.g., sustainability as a performance incentive for administrators), ongoing promotion through professional societies such as National Association of Directors of Nursing Administration—LTC, or identifying local champions with long tenure who can influence new leadership in the facility. These strategies need to be tested in future research.

Beyond turnover, however, participants in a majority of our study facilities identified pervasive mistrust and lack of communication between management and direct care staff, which has been previously observed in other LTC facilities [23, 24] and which was reported by our participants to impact their uptake and sustain implementation of CONNECT. While the parent randomized trial is ongoing and measures of the impact of CONNECT are not yet available, we observed that intervention participation rates were substantially lower and observed minimal changes in staff communication measures in facilities where staff reported this type of distrust between direct care staff and management. Therefore, it appears to be critical for both uptake and sustainment that leaders demonstrate their support of a program with visible, active participation; our well-intentioned separation of managers and staff in class sessions had the unintended consequence of aggravating the existing communication divide.

Incentives for sustained behavior change in LTC also need to be carefully considered. Several participants talked about the need for “accountability” to continue behavior change, referring to common LTC practices such as mandatory training, inspections, and penalties for failing to comply with workplace rules. While rule-based management approaches and “shame and blame” work environments are commonly used to develop accountability in LTC, both prior literature and some of our participants suggested that these are likely to be ineffective for sustaining behavior change [24]. Rather, the findings suggest that leaders might encourage institutionalization of the change into the work culture by articulating how it positively impacts shared goals and values. For example, our participants reported being particularly motivated to maintain practices that they believed benefited their residents.

Intervention-level factors that our participants identified as critical for sustainability in LTC included customization and flexibility. Implementation science has long recognized the importance of customization and the tension between continuing programs as originally designed versus the need to adapt them to make program components operational in new environments [2]. Participants in a majority of facilities valued the ability to tailor intervention delivery to accommodate various roles, shifts, and the frequent unforeseen circumstances that arise. In contrast to other healthcare settings with more predictable clinical demands (e.g., outpatient clinics) or higher staff to patient ratios (acute care), it is very challenging to have staff attend regular training sessions during working hours in LTC, and flexibility in how and when education occurs is especially critical. Behavior change interventions sometimes build flexibility into the design, but they rarely test what dose and frequency of “booster” interventions are necessary to sustain the desired level of change. Our study supports prior calls for investigators to clearly define sustainability in context, define outcomes or desired benefits, identify an appropriate measurement time frame, and study fidelity and adaptation [2]. Some investigators have argued that the complexity and heterogeneity of healthcare systems requires a non-linear approach to sustainability that integrates the themes of adaptive, contextually sensitive continuous quality improvement (CQI) and a learning healthcare system with the challenge of intervention sustainment [25]. The “Dynamic Sustainability Framework” argues that interventions must be adapted to fit within individual practice settings and its broader ecological system; since settings and systems change over time, so too must the intervention continuously evolve [20]. The implication is that “intervention optimization” must continue throughout the sustainability phase. This framework may be particularly salient for sustainability in the LTC setting.

Attention to diversity is another intervention-level factor identified by staff that is particularly challenging within LTC. Whereas care in hospital and outpatient settings is delivered primarily by licensed clinical staff with higher educational levels, in LTC, most direct care is delivered by unlicensed staff with high school or equivalent degrees. Behavior change interventions in LTC must therefore span a wider range of clinical expertise and educational levels. Diversity in long-term care also encompasses role/profession, literacy levels, race/ethnicity, and native languages. Intervention developers must use materials that are pertinent and accessible to this diverse target audience and determine a frequency of delivery that optimizes understanding while minimizing excessive repetition. For example, role-play activities in CONNECT were universally acceptable regardless of staff roles; an improvement would be to integrate stories that include a variety of staff roles into the role-play. This approach would better support inclusiveness of non-nursing staff in the learning sessions and could be used to address some of the communication gaps that also impact sustainability.

Our study also confirms findings of sustainability studies in other settings. In a multisite chronic care management intervention study in Sweden, intervention sites that showed the greatest improvement in the first year of the program also demonstrated the highest levels of sustainability [26]. In a study evaluating a teamwork-promoting intervention in emergency departments, groups that did not receive positive feedback from their behaviors did not sustain behavior changes [27]. These studies and our participant comments suggest that individuals are most likely to maintain programs when positive results are clear to them. Regular coaching and program evaluation with participant feedback has been reported to be effective in sustaining quality improvement interventions in home care [28] and was reported to be an effective way to provide feedback on effectiveness by some of our focus group participants. However, some participants wished that managers and not just research staff would acknowledge them for changing their behavior and believed this would have a broad-scale impact on uptake and sustainability.

These findings will be used by our research team in several ways. The main study results on CONNECT are expected in 2016, and if effective, the intervention will be streamlined to include the most salient elements identified by staff during the focus groups. Suggested tools (videos, training manuals) will be developed to facilitate widespread adoption, and intervention sustainability will be measured in a real-world pragmatic study. CONNECT is currently being adapted for use in other healthcare settings which require interprofessional team care within the Department of Veterans Affairs.

This qualitative study limited us to reporting perceptions of LTC staff about sustainability, rather than providing direct evidence of the effectiveness of sustainability approaches; it was a hypothesis-generating study identifying strategies that might be tested in future studies. It is important to note that the effectiveness of the complex intervention in the ongoing parent study, CONNECT, has not yet been fully established; staff perceptions of how helpful CONNECT was in their facility may have impacted their responses in the focus groups. We were limited to eight participating facilities in one region of the USA, which impacted the generalizability of our findings. Nevertheless, we believe that the results provide important insights that interventionists, practitioners, and administrators should consider when designing or deploying complex interventions in LTC. Practical tools to assist in designing sustainable interventions have been developed, such as the United Kingdom National Health System Institute for Innovation and Improvement Sustainability Model Tool to self-assess intervention-level, context-level, and external support factors [29]. Our study provides a rich context within which to interpret and extend these recommendations for LTC research and quality improvement. Additional research is needed to explicitly test sustainability approaches in LTC.

LTC is a unique healthcare setting with particular challenges for intervention sustainability including diversity in staff role and educational level, frequent communication gaps or mistrust between direct care and managerial staff, and high leadership turnover. These factors must be considered when designing and implementing behavioral change interventions in LTC; the suggested approaches from staff described in this study may be helpful but require testing in future studies.

LTC, long-term care; SDC, staff development coordinator; UK, United Kingdom; USA, United States of America