Looking into mechanisms of change: Evaluation of a multifaceted implementation strategy to change pain management behavior of care workers
Abstract BackgroundUnderutilization of evidence-based pain management in nursing homes is common. Evidence towards effective approaches to improve adoption of evidence-based practices in nursing homes is limited. To get a better understanding of the impact of our multi-faceted implementation strategies, care worker training workshops and the introduction of trained pain champions, this study explored the underlying mechanisms of the implementation strategies using behavioral theory.MethodsWe conducted a mixed-methods evaluation alongside an implementation- effectiveness study in four Swiss nursing homes. Based on an a priori contextual analysis in the participating homes implementation strategies were developed. Furthermore, we developed a conceptual framework describing hypotheses concerning determinants of implementation and mechanisms of change underlying our implementation strategies.Care workers’ questionnaire surveys were conducted at baseline (n=136), after three (n= 99) and six months (n=83) to assess self-efficacy in pain management and self-reported guideline adoption. We computed linear mixed-effect models to assess changes over time in self-efficacy and logistic regressions to assess associations between self-efficacy and guideline adoption. Concurrently, we conducted focus groups with care workers (n=8) to explore their response to the implementation strategies and to gain a deeper understanding of the potential mechanisms. After transcription, interview data was analyzed using content analysis.ResultsOverall, there was a significant increase in self-efficacy after three and six months (p<0.001). Self-reported adoption of guideline components ranged between 44% and 73% depending on the component. We found significant associations between self-efficacy and adoption of two guideline components, i.e. performing a comprehensive pain assessment and using an observational pain assessment tool in cognitively impaired residents.Qualitative findings showed that the training workshops and pain champions were received positively by care workers. Focus group participants reported to be more attentive to residents` pain experience and to assess and document pain more frequently and with more detail than before.ConclusionsOur findings highlight the importance of continuous commitment of an implementation facilitator, e.g., a pain champion, within an organization. Regarding persistent implementation challenges, a theory-based conceptual model contributes to the overall understanding.Trial registrationClinicalTrials.gov (NCT03471390)