Implementing a training intervention to support caregivers after stroke: a process evaluation examining the initiation and embedding of programme change

Abstract

BackgroundMedical Research Council (MRC) guidance identifies implementation as a key element of the development and evaluation process for complex healthcare interventions. Implementation is itself a complex process involving the mobilization of human, material, and organizational resources to change practice within settings that have pre-existing structures, historical patterns of relationships, and routinized ways of working. Process evaluations enable researchers and clinicians to understand how implementation proceeds and what factors impact on intended program change. A qualitative process evaluation of the pragmatic cluster randomized controlled trial; Training Caregivers after Stroke was conducted to examine how professionals were engaged in the work of delivering training; how they reached and involved caregivers for whom the intervention was most appropriate; how did those on whom training was targeted experience and respond to it. Normalization Process Theory, which focuses attention on implementing and embedding program change, was used as a sensitizing framework to examine selected findings.ResultsContextual factors including organizational history and team relationships, external policy, and service development initiatives, impinged on implementation of the caregiver training program in unintended ways that could not have been predicted through focus on mechanisms of individual and collective action at unit level. Factors that facilitated or impeded the effectiveness of the cascade training model used, whether and how stroke unit teams made sense of and engaged individually and collectively with a complex caregiver training intervention, and what impact these factors had on embedding the intervention in routine stroke unit practice were identified.ConclusionsWhere implementation of complex interventions depends on multiple providers, time needs to be invested in reaching agreement on who will take responsibility for delivery of specific components and in determining how implementation and its effectiveness will be monitored. This goes beyond concern with intervention fidelity; explicit consideration also needs to be given to the implementation process in terms of how program change can be effected at organizational, practice, and service delivery levels. Normalization Process Theory’s constructs help identify vulnerable features of implementation processes in respect of the work involved in embedding complex interventions.

ImPACT: a multifaceted implementation for conversation partner training in aphasia in Dutch rehabilitation settings

“…The main findings in this study were based on questionnaire responses which carry with them, the danger of bias and socially desired responses. Nonetheless, the type of study justified the use of questionnaires [20] and our findings resonate well with findings from other implementation efforts [13] [22] [23] [24], in which the contrast between positive attitudes and organisational (financial) barriers is described. The three features of successful implementation as set out by the 'Promoting Action on Research in Health Services' framework (PARiHS [8]) fit our conclusions.…”

“…Time constraints are a recurring theme in implementation projects [13] 28 [22] [23] [24] [53] and were described as a common barrier in many implementation efforts within the 'Revalidatie Nederland Innovation Programme' [54]. Centres underestimated the time required to get acquainted with the new method and for all team members to fully think through the consequences of a new approach and how this related to current choices and procedures.…”

“…When knowledge remains available to only a few professionals, it is more vulnerable for sustained use. Although using knowledge brokers has become a regular method in implementation [13] the evidence of knowledge brokers' contributions to implementation needs more research [14]. The choice for SLTs as knowledge brokers in this case was based on the contents of the new treatment.…”

Impact of Informal Caregivers Training Program On Geriatric Patients’ Functional Status and Post-Stroke Depression

“…Previous researches demonstrate that stroke survivors and their caregivers often lack the information necessary to help manage the recovery process at home 17,18 . Moreover, informal caregivers face the dual challenge of coming to terms with the sudden onset and subsequent disabling impact of stroke and the realization that the person may require long-term support 19 . Training caregivers in skills essential for the day to day management of disabled elder with stroke is likely to have a role in reducing the burden of care and contribute to improved patients outcomes.…”

The Person, Interactions and Environment Programme to improve care of people with dementia in hospital: a multisite study

“…87,88 l Were the strategies employed to engage staff (interactive workshops and manual) sufficient to engender a sense of purpose around the beliefs and values that inform person-focused care for people with dementia (coherence)? l Was the process for leading and implementing PIE (team and service improvement cycle) perceived as worthwhile and feasible to invest in to effect change in ward culture and practice (cognitive participation)?…”