Implementation of interventions to maintain and promote the functional mobility of nursing home residents – a scoping review

Background To provide an overview of the available evidence on the implementation of direct and capacity-building interventions to promote and maintain the functional mobility of nursing home residents. Methods We conducted a scoping review following the methodological guidance for the conduct of scoping reviews as described by the Joanna Briggs Institute. We searched for studies in MEDLINE (via PubMed) and CINAHL (via EBSCO). We conducted a qualitative content analysis of the included studies with deductive categories based on the Consolidated Framework for Implementation Research (CFIR). Results Ultimately, we included 8 studies on direct interventions, 6 studies on capacity-building interventions, and 2 studies on both types of interventions in our review. Seven studies provided evidence on implementation strategies comprising discrete as well as multifaceted, multilevel strategies. Most of the studies did not systematically evaluate the strategies but remained at a descriptive level. All 16 studies provided evidence of influencing factors. We identified 32 of the 37 influencing factors of the CFIR. The five most frequent influencing factors were available resources (n = 14), access to knowledge and information (n = 12), patient needs and resources (n = 10), knowledge and beliefs about the intervention (n = 10) and compatibility (n = 9). Conclusions The available evidence on the implementation of functional mobility interventions in nursing homes is rather limited. This emphasizes the need for further research. Regarding implementation strategies, the systematic evaluation and further development of the reported promising approaches might be a starting point. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-023-04213-5.

Most of these negative consequences frequently occur for nursing home (NH) residents, and thus, the decline of physical performance is also evidently associated with them [17,18].Given this situation, maintaining and enhancing functional mobility are important factors for preventing health restrictions and increasing the care dependency of NH residents.Thus, maintaining and enhancing functional mobility are pivotal tasks of professional care in NHs [16,19].
Many interventions are available to enhance functional mobility and to prevent the functional decline of residents.In addition to interventions that focus directly on the behavior of the person whose functional mobility is to be maintained or enhanced (e.g., exercise programs, walking programs), there is an increased awareness that interventions that aim to improve organizational capacity to promote the functional mobility of residents are needed as well (e.g., education for nursing staff or environmental changes) [20].Either type of mobility intervention tends to be quite complex and to comprise a variety of components [21][22][23].
For the development of such complex interventions, it is strongly recommended not only that the outcomes of the intervention be evaluated but also that the process of implementing the intervention be considered [24][25][26][27].This is especially recommended since the benefit depends not only on the effectiveness of the intervention itself but also on its successful implementation in real-life settings [27].Multiple factors can influence such implementation processes [28,29] and need to be addressed by tailored implementation strategies [30].
To ensure the effective and sustainable implementation of mobility interventions, these influencing factors need to be considered and implementation strategies need to be systematically investigated.However, to date, such implementation aspects of mobility interventions have only marginally been investigated, and to our knowledge, a comprehensive and systematic overview of evidence is missing.
To close this research gap, we conducted a scoping review with the objective to identify and descriptively summarize the available evidence on implementation strategies and influencing factors for the implementation of interventions to promote and maintain the functional mobility of NH residents.

Methods
Scoping reviews are especially recommended to explore the extent of the available literature and to map and summarize the evidence in a given field [31].Thus, to conduct this review, we followed the methodological guidance for the conduct of scoping reviews as described by the Joanna Briggs Institute [31,32].Accordingly, we used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [33] for the reporting of the review (Supplementary Table S1).Furthermore, we developed an internal review protocol to guide the process.

Literature search
We developed two separate search strategies addressing the two different types of mobility interventions (A, B).
For the development of the search strategies, we adapted the 'Population, Concept of interest, Context (PCC)' mnemonic [31] and clustered our search terms accordingly: population = nursing home (1); concept of interest = implementation strategies and influencing factors for the implementation (2); and context = interventions to promote and maintain the functional mobility (3).We developed a set of search terms for each PCC element, which we adapted after an initial explorative search.We combined the PCC elements into two search strategies.While we differentiated element 3 (context) with regard to the type of mobility intervention (A, B), elements 1 and 2 remained the same for both search strategies.Additionally, we used key publications to identify free search terms and indexing words.The search strategies were developed by two reviewers (TQ, CM) and were then reviewed and discussed within the project team (TQ, CM, MRM, JIB, MR) and with the Bundeszentrale für gesundheitliche Aufklärung (BZgA)(CR) based on the Peer Review of Electronic Search Strategies [34].Searches were conducted in the following electronic databases: MEDLINE (via PubMed) and CINAHL (via EBSCO).The search strategy was first developed for MEDLINE (Supplementary Table S2) and then adjusted for CINAHL with RefHunter V.5.0 [35].The searches were conducted in November 2020.Additionally, we performed backward and forward citation tracking via reference lists of the included studies.

Study selection
We defined the inclusion criteria based on the research aims and questions and clustered them according to the PCC mnemonic [36].Additionally, we defined criteria for the type of evidence and language (Table 1).
References identified through our literature search were imported into Covidence software [39] and automatically checked for duplicates.Titles and abstracts of the remaining references were independently screened against the inclusion criteria by two reviewers (TQ, CM).Divergent ratings were discussed between the two reviewers, and in case of no consensus, the respective references were discussed with selected coauthors (MRM, JIB, MR).For the full-text screening, we applied the same strategy.Covidence software [39] was used for both screening steps.

Data extraction and management
We adapted the Joanna Briggs Institute template for scoping reviews [36] for data extraction.According to the procedures described by the Joanna Briggs Institute [36], we developed the final data extraction template in an iterative process.This means that we validated and adjusted the initial template, while the first studies were extracted until all relevant data were represented with the template.Finally, the following data were extracted from all studies: study name, authors, year of publication, country, study aim, study design, methodological/ theoretical approach, methods, sites, study population, mobility intervention (incl.target population), implementation outcomes, evidence on 1) implementation strategies and 2) factors influencing implementation.Data extraction was performed by one reviewer (TQ) and then crosschecked by a second reviewer (CM).

Data analysis and synthesis
The identified implementation strategies are summarized descriptively.
To analyze the influencing factors of implementation in the included studies, we conducted a qualitative content analysis [40].We derived the initial deductive categories from the Consolidated Framework for Implementation Research (CFIR) [29] (Supplementary Table 3).Using MAXQDA V. 2020.2.0 [41], the included studies were coded by one reviewer (TQ or CM), and each was cross-checked by the other reviewer.Both reviewers discussed divergent ratings, and recoding was undertaken if necessary.

Stakeholder conference
We presented the findings to and discussed them with CR (BZgA) and five stakeholders from different welfare organizations in long-term care to confirm and refine our interpretations.The stakeholders were managers and project managers, who were responsible for organizational development and quality improvement within their organizations on a regular basis.

Results
Through the electronic database searches, we identified a total of 2218 (A) and 1841 (B) records.After deduplication, we screened 1666 (A)/1453 (B) titles and abstracts for relevance, which resulted in the screening of 111 (A)/72 (B) full texts.Finally, we included 16 studies reported in 21 reports  in the review (Fig. 1).

Sites:
• inner-city skilled nursing and living center (n = 1) Study population: • residents (n = 13) Intervention: • walking program Canada Aim: to assess the effect of the sit-tostand activity (evidence) on the mobility outcomes of nursing home residents, the effect of an audit-and feedback intervention (facilitation) on the uptake of the sit-to-stand activity by healthcare aides, and the contextual factors influencing the uptake of the activity (context) Study design: • quasi-experimental pilot study Methodological/theoretical approach: • Promoting Action on Research Implementation in Health Services (PARIHS) framework Methods: • documentation of resident performance of the sit-to-stand activity, interview-based survey, Alberta Context Tool (56-item survey instrument) Sites: • nursing homes (n = 2) Study population: • residents (n = 45) • health care aides (n = 56)

[55] Canada
Aim: • to determine the effectiveness of a novel knowledge translation intervention, the peer reminder, compared to a standard paper reminder intervention • to examine reminder intensity and reminder frequency on the 1-year sustainability of care aides completing and documenting a mobility intervention with residents living in care facilities Study design: • cluster randomized controlled trial, using a stratified factorial design Methodological/theoretical approach: • not reported Methods: • recording of the conduct of the sit-tostand activity; questionnaires to assess frequency, duration, content, deviations, modifications of the reminders as well as additional reminders; direct observation to assess the fidelity of the paper reminder intervention Sites: • long-term care facilities (n = 8) • assisted living facilities (n = 15) Study population: • residents (n = 349) • care aides (peer reminder) (n = 54)

Kagwa et al. 2018 [43] Canada
Aim: • to explore the experience of healthcare aides encouraging residents living in residential care facilities to complete the sit-tostand activity • to identify the strategies healthcare aides use to integrate this activity into their work routines Study design: • qualitative substudy of the START study (cluster randomized controlled trial) Methodological/theoretical approach: • not reported Methods: • semistructured interviews Sites: • long-term care facilities (n = 2) • assisted living facilities (n = 5) Study population: • health care aides (n = 7)

Intervention:
▪ 'Sit-to-stand mobility activity': • quantitative pre-post-substudy of the START study (cluster randomized controlled trial) Methodological/theoretical approach: • not reported Methods: • analysis of documentation sheets/resident charts

Intervention:
▪ Daily Activities and Independence by NURsing Staff Encouragement" (DAIly NURSE) • multicomponent nursing intervention • aims to change nursing staff behavior in a way that nursing home residents are encouraged & supported to perform their daily activities as independently as possible • components: education, coaching-onthe-job and policy Target population: ▪ nursing staff 2

Projekt ExMo
Görres et al. 2016 [62] Germany Aim: to evaluate the exemplary implementation of the draft expert standard "Maintenance and promotion of mobility in care" Study design: • cluster randomized trial & observational study Methodological/theoretical approach: • not reported Methods: • nursing records, staff survey, questionnaires, process documentation, structural data, cost data, telephone interviews Sites: • nursing homes (n = 33

Mobility intervention Evidence a
Henskens et al.

[60] Netherlands
Aim: • to test the effect of movement-oriented restorative care (MRC) among NH residents with moderate to severe dementia • additionally, data was collected regarding the degree of implementation, and the barriers to the implementation process Study design: • process evaluation within a quasi-experimental study Methodological/theoretical approach: • theoretical elements from previous studies Methods: • only process evaluation: questionnaires, focus groups

Sites:
• locations of a long-term care organization (n = 2) Study population: Intervention: ▪ 'Movement-oriented Restorative Care' (MRC) • derived from the concept of functionfocused care = multidisciplinary approach toward nursing home dementia care that focuses on stimulating physical activity & independent functioning • key elements: educating nursing staff and families, establishing goals with each resident, administering process evaluations to determine the extent to which MRC was implemented as intended Target population: ▪ nursing home residents with dementia 2 Kuk et al. 2017 [57] Netherlands Aim: to evaluate the feasibility of the TIPtoolbox, an instrument developed to support nursing staff step-by-step in implementing an innovation in nursing homes in order to further improve the toolbox for the needs of its end-users Study design: • feasibility study with a mixed-methods design Methodological/theoretical approach: • Medical Research Council (MRC) guidance for process evaluation of complex interventions [25] • work by Saunders et al. [64] Methods: • questionnaires, telephone interviews, participant observations, and focus group interviews Sites: • nursing homes (embedded in the Living Lab in Aging and Long-Term Care)(n = 3) Study population: • registered nurses (n = 12) • vocationally trained (n = 9) • bachelor educated (n = 3)

Intervention:
▪ 'Translating Innovations into Practicetoolbox' (TIP-toolbox) • supports nursing staff in developing a structured and tailored implementation plan to sustainably implement an innovation in a specific setting • based on implementation of change model by Grol et al. [66] • paper booklet or PDF format, supplemented with electronic tools • focus of this feasibility study: implementation of innovations related to the promotion of functional activity Target population: • nursing staff (TIP-toolbox) Aim: • to explore with nursing assistants their feelings and experiences related to restorative care nursing activities after participating in the implementation of a restorative care program Study design: • qualitative study Methodological/theoretical approach: • not reported Methods: • focus groups Sites: • nursing home (n = 1) Study population: • nursing assistants (n = 13) Intervention: • • to explore nursing assistants' experience in participating in a restorative care intervention study Study design: • qualitative study Methodological/theoretical approach: • not reported Methods: • focus groups Sites: • nursing homes (n = 6) Study population: • nursing assistants (n = 93) Intervention: • ▪ care home residents

Organizational capacity building intervention
▪ activities aimed at changing the culture of the homes so that residents would be supported and encouraged to be more active: • physiotherapy assessments and exercise prescriptions for all residents • advice for staff on ways to safely increase the mobility of the residents • provision of simple aids to maximize individuals' mobility • formal care home staff training on recognizing depression and the potential importance of promoting physical activity in residents Target population: • to report on the implementation of a physical activity (PA) scheme -Let's Motivate (LM) • to provide an insight into the different factors which might contribute to its success and further Study design: • qualitative case study design Methodological/theoretical approach: • a series of theoretical resources Methods: • one-to-one semistructured interviews

Sites:
• private care homes (n = 2) Study population: • key staff from each care home (n = 6) • support workers (n = 5) • senior support worker (n = 1) • regional manager of the care homes (n = 1)  • The audit and feedback intervention was associated with increased intervention uptake over time • Uptake increased in site 1, where the initial uptake was weak.In contrast, the uptake in site 2 was higher in the beginning and remained relatively constant

MOVE study
Slaughter et al.

Discussion
In this scoping review, we identified 16 studies [43][44][45][46][47][48][49][50][51][52][53][56][57][58][59][60][61][62] that provided evidence on the implementation of interventions to promote or maintain the functional mobility of NH residents.Most of these studies presented evidence regarding factors influencing such implementation processes [43][44][45][46][47][48][49][50][51][52][53][56][57][58][59][60][61][62], but the scope and depth of evidence varied between the studies.Studies systematically covering a broad range of different implementation aspects were mostly missing and were most likely to be found among those few studies that provide evidence on implementation strategies [42, 44-46, 51, 57, 62].However, even among these studies, only the research program on the sit-to-stand activity examined implementation aspects with a successively developed step-by-step approach and with a long-term perspective considering study results from the previous steps to develop tailored implementation strategies [42,45,46].This may reflect the lack of systematic approaches to designing implementation research [67], which was also underlined by a scoping review by Yang et al. 2020 [68].In their review, the authors included RCTs on the effectiveness and implementation of recreational therapy programs to enhance functional mobility.Even though they were able to derive some evidence on implementation issues, the included RCTs mainly focused on intervention effectiveness.
Overall, it can be stated that the implementation of mobility interventions for NH residents has thus far been insufficiently investigated.Nevertheless, this review brings together the evidence available to date on this topic and thus provides valuable indications for the successful implementation of such interventions.

Implementation strategies
Those studies that examined implementation strategies showed a range of different approaches.The study program of Slaughter et al. [42,43,45,46,51,54,55] referred to a simple direct mobility intervention and examined discrete implementation strategies [69], while the other studies examined either more complex organizational capacity building interventions [57,62] or more complex implementation approaches [44,57,62].
Reminder systems, as systematically investigated by Slaughter et al. [45,46], are common and listed in different taxonomies of implementation strategies (e.g.[69][70][71]).The findings that Slaughter et al. [45] reported have been supported by other studies.Cheung et al. [72] concluded from an overview of 35 systematic reviews that reminder systems are effective in improving healthcare professionals' behavior and that they are more likely to be effective if they are tailored to the respective care setting.In this regard, the literature describes very different types of reminders, ranging from very simple to highly complex formats [72].Thus, the systematic approach described by Slaughter et al. [45,46] to investigate different reminder systems meets these requirements.
Görres & Rothgang [62] suggested that that the combination of education sessions and accompanying implementation strategies was a successful strategy for the implementation of the national expert standard "Maintenance and promotion of mobility in care".Generally, educational meetings are considered to be established in routine care and effective in improving professional practice [69,73], but Forsetlund et al. [73] pointed out that "educational meetings alone are not likely to be effective for changing complex behaviours" (p. 1).Thus, the combination of educational sessions and additional implementation interventions as used by Görres & Rothgang [62] seems promising.
Often, not a single implementation strategy but rather multiple, more complex implementation strategies are used.For example, Powell et al. [69] understood their compilation of implementation strategies as a "list of discrete strategies that can serve as 'building blocks' for constructing multifaceted, multilevel implementation strategies" (p. 7).In line with this, Slaughter et al. [42,43,45,51] also combined reminder systems with other strategies (e.g., audit-and-feedback intervention, informal walkabouts) and conclude this to be supportive for implementation success.
For the design of multifaceted, multilevel implementation strategies, it is recommended that they fit the respective implementation context [74,75].However, such tailoring of implementation strategies is particularly challenging [30].In particular, the consideration of context-specific implementation determinants seems crucial for success [75,76].Accordingly, the approaches described in the studies by Kuk et al. [57] and Kazana & Pencak Murphy [44] are of interest, since both represent a comprehensive implementation approach focused on organizational development.In particular, the TIP-toolbox by Kuk et al. [57] represents a systematic approach for developing a tailored implementation strategy.The TIP-toolbox not only considers barriers and facilitators for the implementation but also represents a theory-driven and step-bystep approach that is guided by the implementation of change model [66].This can be understood as a key success factor since theoretical framing is reasonable for the development and application of tailored implementation strategies [69,77].Additionally, Kazana & Pencak Murphy [44] considered barriers and facilitators within their approach.
In summary, the studies investigated a spectrum of promising implementation approaches.However, only the research program on the sit-to-stand activity showed a step-by-step and long-term approach.

Influencing factors
All of the included studies reported influencing factors of the implementation of mobility interventions for NH residents.These influencing factors relate to the process of implementing mobility interventions.In this respect, the findings of our scoping review indicate which facilitating and inhibiting factors need to be considered when implementing mobility interventions into real-life settings.However, based on the findings, no statements can be made regarding the impact and causal connections of the mobility interventions applied in the identified studies.
Altogether a broad range of influencing factors was identified, which included almost all influencing factors that the CFIR comprises.Available resources, access to knowledge and information, patient needs and resources, knowledge and beliefs about the intervention and compatibility were identified as the most frequently reported influencing factors.Reviews addressing the implementation of other interventions, such as complex interventions in general, fall prevention or guidelines in NHs, have identified similar influencing factors [78][79][80][81].In particular, lack of time, staffing ratio, missing equipment and training have been described as barriers [78][79][80][81] to the implementation of various interventions in NHs, and they represent a vital challenge of the conditions in this care setting.Abilities, attitudes, expectations of residents and the influence of relatives have also been described as important influencing factors in other reviews [79][80][81].Implementation strategies such as resident and involvement of the relatives, knowledge transfer, and tailoring of interventions can be used to address this kind of factor that influences implementation.The matching tool developed by Waltz et al. [75] could -for example -be used to specifically address known barriers with suitable implementation strategies.
Regarding the different types of interventions (direct (A) vs. organizational capacity-building (B) interventions), no major differences in the influencing factors could be identified.The five most important influencing factors were reported with somewhat equal frequency relative to both types of interventions (A and B).Different influencing factors of the CFIR inner setting domain and its networks and communication and culture constructs were more often identified as influencing factors for the capacity-building interventions than for the direct interventions.Conversely, more influencing factors related to the CFIR domain characteristics of the intervention were identified for the direct interventions.

Limitations
The scoping review had some limitations.The concept of organizational capacity-building interventions lacks an internationally established definition.Since the term "Verhältnisprävention" covers this concept for the German context, we built our search strategy B based on the definition of this term [82,83].However, an internationally accepted definition might have led to other aspects to be considered.Furthermore, we only included studies in English and German, and no librarian was involved in the development of the search strategies.However, the researchers involved had both subject-specific and methodological expertise in conducting reviews.Despite the limitations just described, we were able to generate valuable findings.Above all, the systematic approach based on proven standards [32] and the ongoing exchange within the research team contributed to this.

Conclusions
The results of the review provide an overview of the currently rather limited evidence on the implementation of interventions to promote and maintain the functional mobility of NH residents.In particular, there have been few studies examining implementation strategies.However, these studies provide some promising approaches that can serve as a starting point for further research.Studies that evaluate discrete implementation strategies for direct mobility intervention (e.g., the sit-to-stand activity) as well as studies that further develop multifaceted, multicomponent implementation approaches (e.g., the TIP-toolbox) with a focus on complex interventions that also include capacity-building components are recommended here.In contrast, many of the studies reported influencing factors of the implementation.According to our findings, the implementation of mobility interventions especially required sufficient resources, access to knowledge and information for all staff, and consideration of the needs and resources of residents and their relatives.These findings can be considered in practice and research for the development of tailored strategies for the implementation of mobility interventions.Furthermore, the identified indications of differences between (A) direct and (B) capacity-building interventions might be considered in the process of developing tailored implementation strategies.However, further research is needed on this topic.
Finally, it is important to emphasize that the impact of the review's findings extends beyond intervention studies in nursing home settings alone, and therefore hold relevance and value for various types of research in nursing homes and other geriatric care settings.They can provide guidance and insights for researchers and practitioners exploring different aspects of nursing home and geriatric care, including e.g., practice and quality improvement initiatives, resident well-being, or policy development.
Considering (A) direct interventions as well as (B) organizational capacity-building interventions we addressed the following two research questions: -What strategies for the implementation of (A) direct interventions and (B) organizational capacity-building interventions to promote and maintain the functional mobility of NH residents have been investigated?-What factors influence the implementation of (A) direct interventions and (B) organizational capacity-building interventions to promote and maintain the functional mobility of NH residents?

Table 1
Inclusion criteria

Table 2 (continued) General information Study aims, design & methods Participants Mobility intervention Evidence
inpatient care facilities** Study population: ▪ management** ▪ quality management** ▪ nursing staff** ▪ trainers** a Aging and new media Juul et al. 2019 [47] Australia Aim: to investigate the role of touchscreen technology in facilitating increased physical activity and stimulating social interaction in RACFs in order to decrease social & physical inactivity Study design:

Table 3
Overview of the implementation strategies identified within the included studies

Table 4
Overview of the influencing factors identified within each study