Importance of Team Functioning as a Target of Quality Improvement Initiatives in Nursing Homes: A Qualitative Process Evaluation

Introduction: Quality improvement interventions demonstrate variable degrees of effectiveness. The aim of this work was to (1) qualitatively explore whether, how, and why an academic detailing intervention could improve evidence uptake and (2) identify perceived changes that occurred to inform outcomes appropriate for quantitative evaluation. Methods: A qualitative process evaluation was conducted involving semistructured interviews with nursing home staff. Interviews were analyzed inductively using the framework method. Results: A total of 29 interviews were conducted across 13 nursing homes. Standard processes to reduce falls are well-known but not fully implemented due to a range of mostly postintentional factors that influence staff behavior. Conflicting expectations around professional roles impeded evidence uptake; physicians report a disconnection between the information they would like to receive and the information communicated; and a high proportion of casual and part-time staff creates challenges for those looking to effect change. These factors are amenable to change in the context of an active, tailored intervention such as academic detailing. This seems especially true when the entire care team is actively engaged and when the intervention can be tailored to the varied determinants of behaviors across different team members. Discussion: Interventions aiming to increase evidence-based practice in the nursing home sector need to move beyond education to explicitly address team functioning and communication. Variability in team functioning requires a flexible intervention with the ability to tailor to individual-and home-level needs. Evaluations in this setting may benefit from measuring changes in team functioning as an early indicator of success.