Table 5 Implementation determinants related to the experiences of healthcare professionals

Belief in usefulness

The belief that the programme would be useful to improve the services of the geriatrics department and lead to better patient outcomes fuelled the implementation.

Quote 1: “The literature demonstrated that co-management had better outcomes than geriatric consultation, and we were looking for ways to improve our liaison services. So we wanted to investigate if this model, that focusses more on an integrated collaboration between teams, has better outcomes.” - HP1

Project communication

Personal contacts between the project team and the participating healthcare professionals and informal contacts between the participating healthcare professionals were key in creating awareness of the programme, and were preferred over emails and telephone calls.

Information sessions created awareness, but not necessarily knowledge on how to perform the programme. This was likely moderated by the complexity of the change: information was sufficient if the change was simple and small but not if the change was complex or large.

Quote 2: “I know that there was an email about the programme but I probably did not read it. Because if you start your rotation you receive a thousand emails and you have to start planning your care.” - HP27

Quote 3: “The supervisors knew the programme and when you start here on the unit information will find you … I think that somebody from the programme approached me and I had heard of it so I just asked for some more information. That was really sufficient.” - HP23

Quote 4: “The programme was presented several times and we received a lot of information but there is always uncertainty how things will go once we bring the theory to practice.” - HP11

Co-development

A formal needs assessment was necessary for the development of the programme. The assessment had to go beyond quantitative indicators but also include understanding the care culture and routine on the units. The participating healthcare professionals also found it important to understand each other’s needs and care routine. The involvement of local leaders and champions was not sufficient. Involvement needed to reach all participants to facilitate a feeling of ownership. It was key that the programme was not designed as a study but that participants felt that they could tailor it to their needs.

Quote 5: “If nurses from our team work on the project it creates a lot of enthusiasm and we feel that we are part of it.” - HP21

Quote 6: “It is important to reach all nurses. There is a difference between a head nurse that is involved, and all other nurses ... they may not be so motivated. The nurses can’t have the feeling that they have to do it for a study.” - HP1

Quote 7: “You have to understand practically how they are caring for older patients. We need to work together and experience how things are organised on a daily basis. Then it is easier to see how we can improve care for older patients.” - HP4

Scaled implementation

A scaled implementation approach, i.e. start small and build the volume of the programme over time, facilitated the learning process and the implementation. It allowed healthcare professionals to try the program and adjust it, which decreased the resistance to change.

Quote 8: “At the beginning, we were afraid of the workload but once we started it went really well. The change was not drastically and it helped to find areas of the program that were not working well.” - HP12

Learning & skills development

Learning to perform the programme took time and was moderated by several mechanisms: feedback on performance, checklists, protocols and visual reminders. The stakeholders also suggested that case discussions with the entire team would have been helpful. While experimenting with the programme was perceived as useful, complex skills (e.g. coaching) required formal training.

Quote 9: “It is always an adjustment trying something new and it takes time making that transition … You have to experience it and try do to it on your own and learn through the feedback that we received.” - HP8

Quote 10: “The protocols were useful to have. After seeing your patient, you could review what protocols needed to be implemented.” - HP2

Exposure to the programme

A sufficient caseload (exposure/experience) was needed to learn the programme.

Quote 11: “Sometimes it looks as if nurses had not learned from the programme but they may not have had many experience or may not have seen many patients in the programme”. - HP7

Quote 12: “Because of the high staff turnover in medical residents they had not a lot of exposure to the program and were not always well informed.” - HP11

Feedback & adaptations

Adapting the programme to stakeholder feedback was key to ensuring the feasibility. Regular meetings with the project team and a working group with the participating healthcare professionals facilitated this process. The primary concern was workload and staffing levels. The project team had a central role in collecting the feedback and steering the change. This was both a facilitator and a barrier because it may have inhibited the communication between the different teams. It was also noted that adapting the programme too much may limit the clinical impact as key interventions may be compromised.

Quote 13: “It would have been very difficult to perform the original programme with the available staffing levels. The programme has become more feasible but that may also have changed the effectiveness and the expected level of involvement”. - HP8

Quote 14: “With every step, our feedback was asked and there was a lot of willingness to listen and our feedback was always addressed.” - HP18

Quote 15: “At the working group meetings I could easily discuss the programme with my colleagues and what needed to change … because the program is never really finished.” - HP11

Leadership

Head nurses had a key role in motivating the healthcare professionals to change their care routine, address fears for change and perform the programme. The leadership style was an important moderator. However, this also meant that when the head nurse was absent, the performance dropped.

Quote 16: “Once a new head nurse was appointed we knew that additional staff would be hired. That gave us reassurance and we believed that the programme would be more feasible.” - HP4

Quote 17: “I believe that it very much depends on the head nurse, and how they lead the team … you can see it when the head nurse is not present, then things did not go so well.” - HP11

Management support

The perceived lack of support by management to facilitate a good working environment was considered a barrier and was probably related to work motivation.

Quote 18: “Our working environment is not really ideal … and we don’t have the support of the hospital management. If we raise our concerns, nothing happens.” - HP8

Resources

Having dedicated resources for the programme was considered important, which included financial resources for dedicated staffing and having a good work infrastructure.

Quote 19: “The staffing levels will really determine if we can make it a success. Now I know that we really need a dedicated nurse every day for the programme.” - HP8

Quote 20: “Initially you start with project funding so you can experiment. But when the project stops and think its valuable you need to be able to continue it.” - HP1

ICT infrastructure

ICT facilitated the integration of the programme in routine care by becoming more visible. It was perceived that its value was limited by the waiting list by ICT-services.

Quote 21: “If you see the risk score for the patient on your screen, you automatically know that the patient is in the programme and that they are working with the patient.” - HP16

Quote 22: “The Electronic Patient Record has many possibilities but our ICT services need time to programme new modules.” - HP4

Competing tasks

The programme was influenced by the larger strategy of the department. Projects and tasks outside the programme were a barrier to performing the programme.

Quote 23: “Medical residents are not really that involved, they have a lot of other tasks and the project is not high on their priority list.” - HP12

Quote 24: “The geriatrician was supposed to see the patients on the units and discuss the care with the residents, but they have received a lot of new tasks since the start of the programme so they don’t have the time anymore.” - HP9