Implementation science in the nursing home

Abstract

Evidence-based practices (EBP), including those that have been widely disseminated, do not automatically move into routine clinical usage for a variety of reasons. These reasons include organizational culture, clinical inertia, lack of time, and lack of funding. As a corrective, a public health initiative referred to as implementation science has developed. Unlike clinical research, which mainly focuses on the patient, implementation science also investigates the healthcare provider, the healthcare organization, and relevant policy settings. Several types of studies are used to address implementation process gaps. These include designs which address the external validity of efficacy or effectiveness studies, designs which address quality gaps, designs which address frontline provider competing demands, and designs which address misalignment with national or local priorities (Bauer et al., 2015). Nursing homes have been relatively slow to implement EBP, likely because of complex contextual factors which limit both the desire for change and the capacity to ensure implementation fidelity. These contextual factors might include low staff-to-resident ratios, high staff turnover, lack of leadership, and absence of management support (Appelhof et al., 2018). However, a number of recent studies in nursing home residents have employed implementation science methodology, often built on an effectiveness trial. For example, there have been process evaluations of an advance care planning intervention (Aasmul et al., 2018), an intervention to prevent the use of physical restraints (Abraham et al., 2019), and an intervention to improve pain management guidelines (Brunkert et al., 2019). Against this background, Gerritsen et al. (2019) report their findings from a process evaluation of the intervention employed in an effectiveness study of psychotropic medication reviews in Dutch nursing home residents with dementia (the PROPER study; van der Spek et al., 2016). The intervention arm of the study involved three components: education sessions, medication reviews, and evaluation meetings. The biannual medication reviews involved a physician, a pharmacist, and a responsible licensed practical nurse (RLPN). Importantly, in theNetherlands, elderly care physicians are employed by long-term care organizations and pharmacists are permanently involved as consultants in nursing homes. At each of the biannual medication reviews, all of the residents in each of the intervention dementia care units were reviewed. In their process evaluation, the investigators assessed the quality of the intervention, the implementation strategies delivered and received, and the barriers and facilitators to implementation. It should be noted that medication reviews were already occurring in some nursing homes included in the study, so the intervention was not entirely novel. Gerritsen et al. (2019) found high levels of staff engagement, with a 95% participation rate in preparation and education, a 100% completion rate for medication reviews, and an 82% participation rate at evaluation meetings. Among RLPNs, there was a much lower rate of making observations of medication side effects – only 14 of 30 (47%) RLPNs reported doing this. There was also a more modest rate of using the PROPERpreparation checklist in conductingmedication reviews. This was done in only 56% of reviews. Furthermore, some RLPNs reported that they found the medication-focused training difficult. An implementation coordinator was considered to be an important facilitator of the medication review intervention and outside assistance from the study investigators was needed at times. Barriers to implementation included time and staff turnover. It appears that the time that RLPNs used to conduct their medication reviews was not backfilled. The introduction of additional tasks such as medication reviews is unlikely to gain traction unless they are appropriately remunerated. Where physicians and pharmacists are involved, it is important to understand how their involvement is funded. The findings from Gerritsen et al. (2019) might not generalise well to jurisdictions where these health workers are financially independent of the nursing home organization and bill their patients directly. A cost-benefit analysis was not reported. Medication reviews should involve nursing personnel who know the patients well, but it is important that they have additional scheduled paid time that does not compete with the need to provide direct patient care. Although the investigators refer to the importance of involving stakeholders, input from the people with dementia and their family members (or other substitute decision makers) was conspicuous by its absence. When prescribing decisions involve modest benefits and serious potential risks, as is the case with the use of International Psychogeriatrics (2021), 33:9, 865–866 © International Psychogeriatric Association 2021