How Stories Can Contribute Toward Quality Improvement in Long-Term Care.

It is important to evaluate how residents, their significant others, and professional caregivers experience life in a nursing home to improve quality of care based on their needs and wishes. Narratives are a promising method to assess this experienced quality of care as they enable a rich understanding, reflection, and learning. In the Netherlands, narratives are becoming a more substantial element within the quality improvement cycle of nursing homes. The added value of using narrative methods is that they provide space to share experiences, identify dilemmas in care provision, and provide rich information for quality improvements. The use of narratives in practice, however, can also be challenging as this requires effective guidance on how to learn from this data, incorporation of the narrative method in the organizational structure, and national recognition that narrative data can also be used for accountability. In this article, 5 Dutch research institutes reflect on the importance, value, and challenges of using narratives in nursing homes.

Moral learning through caring stories of nursing staff - OK.

BACKGROUND: Implementing person-centred care (PCC) in nursing homes is challenging due to a gap between theory and practice. Bridging this gap requires suitable education, which focuses on learning how to attune care to the values and preferences of residents and take moral, relational, and situational aspects into account. Staff's stories about the care they provide (i.e. caring stories) may deliver valuable insights for learning about these aspects. However, there is limited research on using staff's narratives for moral learning. OBJECTIVE: This study aims to provide insight into the perspectives of nursing staff on using their caring stories to learn about PCC. RESEARCH DESIGN: In this qualitative research, we conducted two rounds of interviews with 17 participants working in nursing homes. We wanted to obtain nursing staff's perceptions of working with their caring stories and the impact on PCC. ETHICAL CONSIDERATIONS: Participation was voluntary, and participants provided written consent. The study protocol is approved by The Institutional Review Board of the Medical Ethical Committee Leiden-Den Haag-Delft. FINDINGS: Working with caring stories enables nursing staff to provide PCC and improves job satisfaction. It increases awareness of what matters to residents, fosters information rich in context and meaning, and enhances voice and vocabulary. Through in-depth team reflections, nursing staff discussed the significant moments for residents, which centralizes the discussions on the moral quality of care. DISCUSSION: Working with caring stories fosters dialogue on PCC and enhances reflection on ethical situations in daily encounters, contributing to the moral development of nursing staff. Putting nursing staff's narratives at the centre of learning suits their daily practice and intrinsic motivation. Therefore, the outcomes of this study are an addition to the existing literature about using narratives in long-term care. CONCLUSION: Using nursing staff's narratives contributes to PCC and positively impacts nursing staff. We recommend using staff's caring stories as a vehicle for moral learning in the transition to PCC.

[The involvement of older adults in the residential care: dilemmas, pitfalls and potentials]. / Betrokken bewoners in het verpleeghuis: dilemma's, knelpunten en kansen.

In the residential care sector we have witnessed throughout the previous decades a development from a rather paternalistic approach towards a more democratic way of care giving. In many care organizations, however, residents are still rarely involved in the daily routine. In a participatory study on a somatic care unit in the Netherlands, we examined the challenges around the involvement of residents in the care residence. We organized two homogeneous group sessions, with staff and residents separately; reflected on new ways for involving residents; and concluded with a heterogeneous focus group, bringing staff and residents together. Both staff and residents recognized the importance of resident involvement in daily care. However, the difference in perspective on what this should look like created challenges. We found three dilemmas that made the engagement of residents challenging: autonomy versus dependence, personal experiences versus privacy, and happiness versus honesty. We found different ways staff and residents dealt with these dilemmas in practice and defined them in terms of bottlenecks and opportunities. Attention to these dilemmas, pitfalls, and potentials, promotes mutual understanding and ultimately resident involvement in daily care.

Older Adults' Engagement in Residential Care: Pitfalls, Potentials, and the Role of ICTs.

Over the previous years, the residential care sector has gone through a transition from a rather paternalistic approach towards a more democratic way of caregiving. Nevertheless, many care organizations still find it challenging to engage their residents in the process of care. In this study, we investigated the challenges regarding the engagement of older adults in residential care. As recent studies indicated the increasing opportunities of ICTs, we paid particular attention to this in the process of engagement. We followed a participatory action research approach among caregivers and older adults at a somatic care department in a care residence in the Netherlands. Methods used included 15 participants in two homogeneous group sessions, reflections on action in practice, and one mixed focus group. Our findings show that both caregivers and older adults acknowledge the importance of engagement in daily care. However, their different perspectives on how this should take place, made the actual engagement of older adults a challenge. We determined three dilemmas complicating this engagement in care, and labeled these (1) autonomy versus dependence; (2) personal experiences versus privacy; and (3) happiness versus honesty. We found different ways of how caregivers and older adults deal with these dilemma's in practice and defined these in terms of pitfalls and potentials. ICTs were shown to reinforce both the pitfalls and potentials. Paying attention to these challenges in residential care, including how caregivers and older adults deal with these challenges, will encourage a mutual understanding and actual engagement in decisions on daily care. Further research is recommended on the role of organizations' management, older adults' relatives, or older adults with cognitive impairments.

Good Care during COVID-19: A Narrative Approach to Care Home Staff's Experiences of the Pandemic.

Due to its major impact on Dutch care homes for older people, the COVID-19 pandemic has presented care staff with unprecedented challenges. Studies investigating the experiences of care staff during the COVID-19 pandemic have shown its negative impact on their wellbeing. We aimed to supplement this knowledge by taking a narrative approach. We drew upon 424 personal narratives written by care staff during their work in a Dutch care home during the COVID-19 pandemic. Firstly, our results show that care staff have a relational-moral approach to good care. Residents' wellbeing is their main focus, which they try to achieve through personal relationships within the triad of care staff-resident-significant others (SOs). Secondly, our results indicate that caregivers experience the COVID-19 mitigation measures as obstructions to relational-moral good care, as they limit residents' wellbeing, damage the triadic care staff-residents-SOs relationship and leave no room for dialogue about good care. Thirdly, the results show that care staff experiences internal conflict when enforcing the mitigation measures, as the measures contrast with their relational-moral approach to care. We conclude that decisions about mitigation measures should be the result of a dialogic process on multiple levels so that a desired balance between practical good care and relational-moral good care can be determined.

Being Active, Engaged, and Healthy: Older Persons' Plans and Wishes to Age Successfully.

OBJECTIVES: This study took an emic multidimensional approach on successful aging and examined what older people consider important to age successfully by asking them about their plans and wishes (PWs). Associations between participants' demographics, health status, working life, social contacts, life satisfaction, and their PWs were investigated. METHOD: An online questionnaire was completed by 649 older individuals (55-90 years). Conceptual content analysis was performed to identify important categories in PWs. Quantitative analyses were conducted to examine associations between PWs and participants' characteristics. RESULTS: Most mentioned PWs were related to activities, engagement with life, and health. Seventy-four participants (11.4%) expressed no PWs. Multivariate analysis revealed that having PWs was most strongly related to participants' life satisfaction. Older individuals with a higher life satisfaction indicated significantly more often to have PWs than individuals with a lower life satisfaction. DISCUSSION: The majority of older people desire an active, engaged, and healthy life. PWs were variable and personal, which endorses an emic, multidimensional approach to successful aging. Knowledge on what older individuals find important in their lives and what they want to achieve can assist older individuals in setting and attaining their goals toward aging well.

Process evaluation of a randomised controlled trial of a diabetes prevention intervention in Dutch primary health care: the SLIMMER study.

OBJECTIVE: To investigate (i) how the SLIMMER intervention was delivered and received in Dutch primary health care and (ii) how this could explain intervention effectiveness. DESIGN: A randomised controlled trial was conducted and subjects were randomly allocated to the intervention (10-month combined dietary and physical activity intervention) or the control group. A process evaluation including quantitative and qualitative methods was conducted. Data on process indicators (recruitment, reach, dose received, acceptability, implementation integrity and applicability) were collected via semi-structured interviews with health-care professionals (n 45) and intervention participant questionnaires (n 155). SETTING: SLIMMER was implemented in Dutch primary health care in twenty-five general practices, eleven dietitians, nine physiotherapist practices and fifteen sports clubs. SUBJECTS: Subjects at increased risk of developing type 2 diabetes were included. RESULTS: It was possible to recruit the intended high-risk population (response rate 54 %) and the SLIMMER intervention was very well received by both participants and health-care professionals (mean acceptability rating of 82 and 80, respectively). The intervention programme was to a large extent implemented as planned and was applicable in Dutch primary health care. Higher dose received and participant acceptability were related to improved health outcomes and dietary behaviour, but not to physical activity behaviour. CONCLUSIONS: The present study showed that it is feasible to implement a diabetes prevention intervention in Dutch primary health care. Higher dose received and participant acceptability were associated with improved health outcomes and dietary behaviour. Using an extensive process evaluation plan to gain insight into how an intervention is delivered and received is a valuable way of identifying intervention components that contribute to implementation integrity and effective prevention of type 2 diabetes in primary health care.

Factors associated with physical therapists' implementation of physical activity interventions in The Netherlands.

BACKGROUND: Physical therapists play an important role in the promotion of physical activity (PA) and the effectiveness of PA interventions. However, little is known about the extent to which they implement PA interventions following the intervention protocol and about the factors influencing their implementation behaviors. OBJECTIVE: The study objective was to investigate physical therapists' implementation fidelity regarding PA interventions, including completeness and quality of delivery, and influencing factors with a Theoretical Domains Framework-based questionnaire. DESIGN: The study was based on a cross-sectional design. METHODS: A total of 268 physical therapists completed the Determinants of Implementation Behavior Questionnaire. Questions about completeness and quality of delivery were based on components and tasks of PA interventions as described by the Royal Dutch Society for Physical Therapy. Multilevel regression analyses were used to identify factors associated with completeness and quality of delivery. RESULTS: High implementation fidelity was found for the physical therapists, with higher scores for completeness of delivery than for quality of delivery. Physical therapists' knowledge, skills, beliefs about capabilities and consequences, positive emotions, behavioral regulation, and the automaticity of PA intervention delivery were the most important predictors of implementation fidelity. Together, the Theoretical Domains Framework accounted for 23% of the variance in both total completeness and total quality scores. LIMITATIONS: The cross-sectional design precluded the determination of causal relationships. Also, the use of a self-report measure to assess implementation fidelity could have led to socially desirable responses, possibly resulting in more favorable ratings for completeness and quality. CONCLUSIONS: This study enhances the understanding of how physical therapists implement PA interventions and which factors influence their behaviors. Knowledge about these factors may assist in the development of strategies to improve physical therapists' implementation behaviors.

Factors influencing primary health care professionals' physical activity promotion behaviors: a systematic review.

BACKGROUND: Despite the promising findings related to the efficacy of interventions aimed at promoting physical activity (PA) in primary health care (PHC), the translation of these interventions to PHC practice does not always happen as desired. PURPOSE: To help understand why efficacious PHC-based PA interventions are not effectively translated to practice, this study systematically reviewed the literature on factors influencing PHC professionals' PA promotion practices. METHOD: Literature searches were conducted in Web of Science, PubMed, and PsycINFO for peer-reviewed articles published in English from 1990 onwards. Studies were included that met the following criteria: (1) involving PHC-based PA interventions, and (2) reporting factors influencing PHC professionals' PA promotion behaviors. Two researchers independently screened studies and extracted data. A narrative synthesis using thematic analysis was conducted to identify factors. RESULTS: Of the 4,469 identified articles, 59 were included in the review. Factors were identified by qualitative methods, barrier/facilitator ratings, and the examination of the relationship between factors and PA promotion, and the effectiveness of introduction strategies. Many factors related to the development, delivery, and effects of the innovation, the sociopolitical and organizational culture, resources, and support, patient and PHC professional characteristics, and innovation strategies were identified as potential influences on PHC professionals' PA promotion practices. However, the lack of evidence on the relationship between factors and PA promotion indicated insufficient evidence on PA promotion determinants. CONCLUSION: This extensive overview of potential factors can inform intervention developers and implementers on which factors may play a role when introducing PA interventions in PHC. Future research should further investigate relationships between factors and PA promotion, which should be guided by qualitative in-depth knowledge on influencing factors.

Factors influencing the introduction of physical activity interventions in primary health care: a qualitative study.

BACKGROUND: The introduction of efficacious physical activity (PA) interventions in routine primary health care (PHC) is a complex process. Understanding factors influencing the process can enhance the development of successful introduction strategies. PURPOSE: The aim of this qualitative study was to explore stakeholders' perceptions on factors influencing the introduction, i.e., adoption, implementation, and continuation, of PA interventions in PHC. METHOD: Twenty-eight semistructured interviews were held with intervention managers, PHC advisors, intervention providers, and referring general practitioners of five PA interventions delivered in PHC. A theoretical framework on the introduction of innovations in health care was used to guide the data collection. Influencing factors were identified using thematic analysis. RESULTS: Stakeholders reported preconditions for the introduction of PA interventions in PHC (e.g., support, resources, and networks and collaborations), in addition to characteristics of PA interventions (e.g., compatibility, flexibility, and intervention materials) and characteristics of PHC professionals (e.g., knowledge, positive attitudes, and beliefs about capabilities) perceived to enhance the introduction process. Furthermore, they proposed strategies for the development of PA interventions (e.g., involvement of future stakeholders, full development, and refinement) and strategies to introduce PA interventions in PHC (e.g., training, assistance, and reinforcement). The majority of the influencing factors were discussed specifically in relation to one or two stages. CONCLUSION: This study presents an overview of factors that are perceived to influence the introduction of PA interventions in PHC. It underscores the importance of taking these factors into account when designing introduction strategies and of giving special attention to the distinct stages of the process.

Measuring determinants of implementation behavior: psychometric properties of a questionnaire based on the theoretical domains framework.

BACKGROUND: To be able to design effective strategies to improve healthcare professionals' implementation behaviors, a valid and reliable questionnaire is needed to assess potential implementation determinants. The present study describes the development of the Determinants of Implementation Behavior Questionnaire (DIBQ) and investigates the reliability and validity of this Theoretical Domains Framework (TDF)-based questionnaire. METHODS: The DIBQ was developed to measure the potential behavioral determinants of the 12-domain version of the TDF (Michie et al., 2005). We identified existing questionnaires including items assessing constructs within TDF domains and developed new items where needed. Confirmatory factor analysis was used to examine whether the predefined structure of the TDF-based questionnaire was supported by the data. Cronbach's alpha was calculated to assess internal consistency reliability of the questionnaire, and domains' discriminant validity was investigated. RESULTS: We developed an initial questionnaire containing 100 items assessing 12 domains. Results obtained from confirmatory factor analysis and Cronbach's alpha resulted in the final questionnaire consisting of 93 items assessing 18 domains, explaining 63.3% of the variance, and internal consistency reliability values ranging from .68 to .93. Domains demonstrated good discriminant validity, although the domains 'Knowledge' and 'Skills' and the domains 'Skills' and 'Social/professional role and identity' were highly correlated. CONCLUSIONS: We have developed a valid and reliable questionnaire that can be used to assess potential determinants of healthcare professional implementation behavior following the theoretical domains of the TDF. The DIBQ can be used by researchers and practitioners who are interested in identifying determinants of implementation behaviors in order to be able to develop effective strategies to improve healthcare professionals' implementation behaviors. Furthermore, the findings provide a novel validation of the TDF and indicate that the domain 'Environmental context and resources' might be divided into several environment-related domains.

Discriminant content validity of a theoretical domains framework questionnaire for use in implementation research.

BACKGROUND: To improve the implementation of innovations in healthcare settings, it is important to understand factors influencing healthcare professionals' behaviors. We aimed to develop a generic questionnaire in English and in Dutch assessing the 14 domains of behavioral determinants from the revised TDF (Cane et al., 2012) that can be tailored to suit different targets, actions, contexts, and times of interest, and to investigate questionnaire items' discriminant content validity. METHODS: We identified existing questionnaires including items assessing constructs within TDF domains and developed new items where needed. Nineteen judges allocated 79 items to one or more TDF domains. One-sample t-tests were used to examine the discriminant content validity of each item, i.e., whether items measured intended domains or whether items measured a combination of domains. RESULTS: We identified items judged to discriminately measure 11 out of 14 domains. Items measuring the domains Reinforcement, Goals, and Behavioral regulation were judged to measure a combination of domains. CONCLUSIONS: We have developed a questionnaire in English and in Dutch able to discriminately assess the majority of TDF domains. The results partly support Cane et al.'s (2012) 14-domain validation of the TDF and suggest that Michie et al.'s (2005) 12-domain original version might be more applicable in developing a TDF-based questionnaire. The identified items provide a robust basis for developing a questionnaire to measure TDF-based determinants of healthcare professionals' implementation behaviors to suit different targets, actions, contexts, and times. Future research should investigate the concurrent and predictive validity and reliability of such a questionnaire in practice.

Factors influencing the adoption, implementation, and continuation of physical activity interventions in primary health care: a Delphi study.

BACKGROUND: The introduction of efficacious physical activity interventions in primary health care is a complex process. Understanding factors influencing the process can enhance the development of effective introduction strategies. This Delphi study aimed to identify factors most relevant for the adoption, implementation, and continuation of physical activity interventions in primary health care by examining experts' opinions on the importance and changeability of factors previously identified as potentially relevant for the process. METHODS: In the first round, 44 experts scored factors on their importance for each stage of the introduction process, as well as on their changeability. In the second round, the same experts received a questionnaire containing a reduced list of factors, based on the first-round results. They were asked to indicate their top-10 most important factors for each stage, and to re-rate factors' changeability. Thirty-seven experts completed this round. RESULTS: Most important factors could be identified for each stage. Some factors were found important for a specific stage, e.g., the presence of intervention champions within the organization (adoption), provider knowledge (implementation), and the intervention's sustainability (continuation), while others were perceived important for all stages, i.e., the intervention's financial feasibility, the intervention's accessibility to the target group, and time to deliver the intervention. The majority of most important factors was perceived changeable. However, for some factors no consensus could be reached regarding their changeability. CONCLUSIONS: This study identified general and stage-specific factors relevant for the introduction of physical activity interventions in primary health care. It emphasizes the importance of taking these factors into account when designing introduction strategies, and of giving special attention to the distinct stages of the process. Due to lack of consensus on the changeability of most important factors, the extent to which these factors can be influenced by introduction strategies remains unclear.