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Published in: Trials 1/2019

Open Access 01-12-2019 | Care | Research

Understanding implementation fidelity in a pragmatic randomized clinical trial in the nursing home setting:a mixed-methods examination

Authors: Jennifer A. Palmer, Victoria A. Parker, Lacey R. Barre, Vincent Mor, Angelo E. Volandes, Emmanuelle Belanger, Lacey Loomer, Ellen McCreedy, Susan L. Mitchell

Published in: Trials | Issue 1/2019

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Abstract

Background

The Pragmatic Trial of Video Education in Nursing Homes (PROVEN) is one of the first large pragmatic randomized clinical trials (pRCTs) to be conducted in U.S. nursing homes (N = 119 intervention and N = 241 control across two health-care systems). The trial aims to evaluate the effectiveness of a suite of videos to improve advance care planning (ACP) for nursing home patients. This report uses mixed methods to explore the optimal and suboptimal conditions necessary for implementation fidelity within pRCTs in nursing homes.

Methods

PROVEN’s protocol required designated facility champions to offer an ACP video to long-stay patients every 6 months during the 18-month implementation period. Champions completed a video status report, stored within electronic medical records, each time a video was offered. Data from the report were used to derive each facility’s adherence rate (i.e., cumulative video offer). Qualitative interviews held after 15 months with champions were purposively sampled from facilities within the highest and lowest adherence rates (i.e., those in the top and bottom quintiles). Two researchers analyzed interview data thematically using a deductive approach based upon six domains of the revised Conceptual Framework for Implementation Fidelity (CFIF). Matrices were developed to compare coded narratives by domain across facility adherence status.

Results

In total, 28 interviews involving 33 champions were analyzed. Different patterns were observed across high- versus low-adherence facilities for five CFIF domains. In low-adherence nursing homes, (1) there were limited implementation resources (Context), (2) there was often a perceived negative patient or family responsiveness to the program (Participant Responsiveness), and (3) champions were reticent in offering the videos (Recruitment). In high-adherence nursing homes, (1) there was more perceived patient and family willingness to engage in the program (Participant Responsiveness), (2) champions supplemented the video with ACP conversations (Quality of Delivery), (3) there were strategic approaches to recruitment (Recruitment), and (4) champions appreciated external facilitation (Strategies to Facilitate Implementation).

Conclusions

Critical lessons for implementing pRCTs in nursing homes emerged from this report: (1) flexible fidelity is important (i.e., delivering core elements of an intervention while permitting the adaptation of non-core elements), (2) reciprocal facilitation is vital (i.e., early and ongoing stakeholder engagement in research design and, reciprocally, researchers’ and organizational leaders’ ongoing support of the implementation), and (3) organizational and champion readiness should be formally assessed early and throughout implementation to facilitate remediation.

Trial registration

ClinicalTrials.gov, NCT02612688. Registered on 19 November 2015.
Appendix
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Metadata
Title
Understanding implementation fidelity in a pragmatic randomized clinical trial in the nursing home setting:a mixed-methods examination
Authors
Jennifer A. Palmer
Victoria A. Parker
Lacey R. Barre
Vincent Mor
Angelo E. Volandes
Emmanuelle Belanger
Lacey Loomer
Ellen McCreedy
Susan L. Mitchell
Publication date
01-12-2019
Publisher
BioMed Central
Keyword
Care
Published in
Trials / Issue 1/2019
Electronic ISSN: 1745-6215
DOI
https://doi.org/10.1186/s13063-019-3725-5

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