“It Was Like a Whole New World Opened Up”: Nursing Home Provider Perspectives on Implementing a Person-Centered Communication Intervention

Beginning in 2016, the US Centers for Medicare & Medicaid Services (CMS) required nursing homes (NHs) to participate in ongoing Quality Assurance and Performance Improvement (QAPI) to help NHs deliver high quality care to residents.¹ Some states require NHs pursue quality improvement (QI) initiatives within certain domains, such as person-centered care (PCC).² PCC, the gold standard of long-term care,³ is a philosophy of care that aims to understand and honor preferences of individuals receiving long-term services and supports.⁴ In the NH setting, PCC involves including residents in care plan discussions and integrating resident preferences into care delivery to create individualized care.⁵ There are several benefits of implementing PCC. PCC has been linked to improvements in quality of care and life for older adults at NHs across the US.⁶ NHs that engage in PCC have greater staff satisfaction and empowerment⁷ as well as staff who prioritize building relationships with residents.⁸ Finally, recent research has found NHs who fully commit to PCC initiatives have fewer deficiencies9 and fewer substantiated reports.¹⁰

Honoring preferences is a core value of PCC. In NHs, this requires open communication between staff and care recipients.^11,12 While the tenants of PCC are well established, there is a continued need for translating PCC into practice. Staff may lack the skills necessary for effective communication, or their communication efforts may be hindered by heavy workloads.¹³ Additionally, previous research has documented barriers to implementing evidence-based PCC such as limited financial resources, staff turnover, and intense workloads.¹⁴ By better understanding the implementation of specific evidenced-based practices, long-term care facilities will be better prepared to implement these interventions.

One evidence-based PCC program is called the Preferences for Activity and Leisure (PAL) Cards. Developed for use in residential long-term care, PAL Cards are personalized 5×7 laminated cards that reflect a resident’s preferred recreational and leisure activities based on information gathered using either the eight-item Minimum Data Set (MDS) 3.0 Section F Activity interview¹⁵ or the 34-item Preferences for Everyday Living Inventory (PELI) interview.¹⁶ The front of each PAL Card includes the individual’s name and a short biography, and the back is personalized to highlight PELI recreation and leisure activities that they have reported as “very important” during their interview (Figure). Cards can then be placed on a resident’s wheelchair, walker, or door as a way to communicate their important preferences to others throughout the community.

Figure. Sample Preferences for Activity and Leisure (PAL) Card.

Studying implementation efforts in NHs is important because there are known barriers to performing QI, such as resource constraints and high turnover, compared with other health care settings.¹⁷ Additionally, implementation in NHs specifically is studied less frequently than other acute settings.¹⁸ Considering these gaps, the purpose of this study was to systematically assess the characteristics of the intervention and process that influence the implementation of PAL Cards in NHs. To systematically assess PAL Card implementation, we used the Consolidated Framework for Implementation Science (CFIR). The CFIR is a conceptual framework that provides a menu of constructs across five domains to identify the barriers and facilitators of implementation efforts.¹⁹ CFIR’s overarching goal is to further “consistent use of constructs, systematic analysis, and organization of findings from implementation studies.”²⁰ In this study, we explore two CFIR domains (Characteristics of the Intervention and Process) to gain a holistic understanding of barriers and facilitators to PAL Card implementation. Within the field of implementing PCC tools in NH settings, these two domains have yet to be explored.

Funding for this research was made possible by the Ohio Department of Medicaid. In Ohio, NHs are required to participate in one QIP approved by the Ohio Department of Aging (ODA) every 2 years and show evidence of completion. The PAL Card project was approved as a QIP and therefore provided a unique opportunity to evaluate implementation by collaborating with NHs that participated in the QIP. The PAL Card project fulfilled the QIP requirement and no additional incentives were provided. ODA approved the PAL Card project and providers were recruited through their website,21 an e-newsletter sent to administrators of all communities in the state, and industry conference presentations. Although 43 NH providers expressed their interest in the QIP, only 26 completed implementation. The most common reasons for providers to drop out of the study were leadership, staff turnover, or both, which were previously cited barriers to NH QI studies.^17,18

Each provider designated a project lead (ie, champion) who guided the implementation team. Providers were asked to complete PAL Cards with 15 to 20 residents. Online training was provided to introduce PAL Cards and discuss the project timeline and required tasks. The project manager held 10 1-hour training sessions with an average of four participants per training. The project manager also facilitated three monthly coaching calls one-on-one with champions to assist with PAL Card implementation. Additional details on PAL Cards and their implementation can be found in the article, “Evaluating the implementation of a pragmatic person-centered communication tool for the nursing home setting: PAL card.”⁴ Miami University IRB approved this study. All participants provided verbal consent before enrollment in this study. Providers were asked to participate in a final telephone interview when they had completed the project. Questions from the CFIR Interview Guide Tool regarding the domains Characteristics of the Intervention and Process, were incorporated into a semi-structured interview. The CFIR is a conceptual framework developed to systematically support the evaluation of implementation facilitators and barriers.²⁰ Interviews were conducted by the principal investigator and project manager by telephone (n=24) or in-person (n=2). Final interview calls were an average of 40 minutes long (range, 28-51 minutes). Interviews were digitally recorded, transcribed verbatim, and checked for accuracy before coding. Data from the present study are derived from the 26 final interview calls.

Nine team members reviewed the telephone interview transcripts multiple times before assigning a primary and secondary coder to each transcript. As CFIR themes were identified a priori, we coded looking for those constructs and counted the number of providers in which the themes emerged. Therefore, we used a combination of a priori thematic framework analysis²² and deductive content analysis.23 A codebook was developed using CFIR construct definitions with examples from our data (Table 1). Coding was completed using Dedoose software. Weekly meetings were held to review code definitions and reconcile any differing codes until consensus was reached. To better understand the degree to which factors influenced implementation, three team members scored every participant excerpt to determine valence. Valence scoring is used to assess directionality (ie, positive, negative, or neutral) and strength of a construct's influence on implementation.²⁴ Possible scores ranged from −2 (strong barrier) to +2 (strong facilitator). A final overall valence score was assigned to each construct via consensus, based upon the most frequently coded value according to CFIR guidelines.²⁵

Table 1. Characteristics of the Intervention and Process CFIR Constructs and Operational Definitions (Codebook)

Abbreviations: CFIR, Consolidated Framework for Implementation Research; NH, nursing home; PAL, Preferences for Activity and Leisure.

Twenty-six providers completed project requirements out of 43 registered. These providers had an average bed size of 87 and an average star rating of 3.7 (SD 1.1; range, 1-5). Most providers (56%, n=14) were not-for-profit or government-owned. Champions were activity directors (84%; n=22), administrators (12%; n=3), and Directors of Nursing (4%; n=1). All 26 champions were women. Table 2 summarizes our content analysis with the number of providers who mentioned each CFIR construct and valence score of each construct.

Table 2. Frequency of Mentions and Valence of Selected CFIR Constructs

Abbreviation: CFIR, Consolidated Framework for Implementation Research.

Evidence Strength and Quality was mentioned most frequently as a strong facilitator to implementation (+2). Providers believed in the value PAL Cards could bring to their communities. Seeing the positive benefits from implementing the cards had motivated providers to continue the project. Provider 3 said:

I can tell you that when the dietary manager came and brought me their questionnaires they were like, "Did you know that this resident did...?" I mean it was like a whole new world opened up because they got to find out things specific to that resident. They weren't just preparing a meal for them. Now they know some things that they can go talk to them about and have a meaningful conversation.

PAL Cards displayed Relative Advantage as a strong facilitator (+2) by discovering and sharing residents’ preferences. One provider reported sharing resident preferences before the PAL Cards through methods developed in-house, such as a “getting to know you” poster. A main advantage of a PAL Card is its ability to move with residents throughout the community. This allowed for more people, such as volunteers or family members, to utilize the cards. Provider 8 said:

The thing that's different about the PAL Cards is that they're actually on the walkers or the wheelchairs. The cards that we had before were like 5×8 cards that we had in a little binder that sat on the nurse aide desk. So, the nurse aides would have to actually pick the book up and look through it, whereas the PAL Cards are right there.

In addition to Evidence Strength and Quality, other intervention characteristics had positive, yet weaker influences on implementation and therefore received a +1 valence rating. The ability to adjust PAL Cards to meet the needs of each community was reported as important to success (Adaptability). One such adaptation was adjusting the number or type of preference questions asked during the resident interview. Another adaptation involved integrating PAL Cards into the normal community routine, including using the PELI questionnaire as part of their assessment process or using PAL Cards in a group activity. Provider 8 said:

We do an initial meeting with new residents that come in, so we had talked about … incorporating that into the initial meeting and just getting that information out front and we could create a [PAL] Card from that as the residents come in, instead of trying to get it later.

Design Quality and Packaging referred to two aspects of the PAL Card project: how the intervention was presented to providers by the research team, and the physical design of the PAL Cards. Providers generally viewed the PAL Card project as well organized. Providers mentioned that being able to call the project coordinator with questions helped them overcome challenges. Provider 15, for example, said, “You really dropped everything to make sure that we had the information that we needed when we needed it.” Providers also reported the physical materials (eg, PAL Card template, project checklists, and tip sheets) were helpful for implementation. Provider 9 said:

I thought everything was very helpful. There were a lot of example cards and everything was in our binder that we have, all the different step-by-step directions. I thought everything was laid out very organized and easy to understand. All the templates were helpful.

Additionally, providers found the ability to trial/pilot PAL Cards on a small scale and then decide whether to continue using them to be a helpful aspect of implementation (Trialability). We anticipated providers would start with residents who could communicate, however, several providers considered residents’ cognitive status when deciding who to target for the pilot effort. Provider 1 said:

… it was like what group of residents are we focusing on first? And the administrator and myself had talked and we decided we would start off with our long-term [residents]. And that's how we started the program—we opted to do the long-term [residents].

Complexity was a weak, negative influence on implementation (valence: −1). Providers mentioned time constraints and technology as barriers. Champions reported it was challenging to incorporate the intervention into their busy schedules. In particular, providers described that doing the project “right” required time to properly execute various steps. Provider 27 said:

Because again everybody probably perceives it as, “Oh, you're just asking a few questions and putting them on a card.” Well, no. You want to make sure the information is right [and] the resident is okay with it. If there is any type of cognitive impairment, you want to talk to the family [and] let them know what's on the card. Make the card, put the card on, remind the resident—I think it's a pretty big project, being kind of a newer associate.

In addition to the complexity, another barrier was staff time (coded under the CFIR construct of Cost, valence rating of −1). Providers found staffing and time to be the most costly parts of implementing PAL Cards. Activity professionals typically spearheaded the PAL Card project. These staff reported having other responsibilities, which made completing the PAL Cards challenging. One provider described how their activity staff were also state-tested nursing assistants (STNAs), and so finding time to do PAL Cards while balancing resident care was difficult. Provider 8 said:

It just boiled down to time constraints because all of our activity people are also STNAs, so we've had to assist with residents in various capacities. Unfortunately, we were going to try to get volunteer help, but our volunteer staff had some illnesses.

Within the Process domain, Engaging was mentioned most frequently as a positive influence on implementation, followed by Executing and Reflecting and Evaluating (all valence: +1). Engaging others, including staff and residents’ families, was a major part of PAL Cards. Project champions reported sharing information at regular staff meetings/huddles, one-on-one interactions, designated in-services/training sessions, and through bulletin boards/flyers. Provider 6 said:

I think what really helped was … when we had the all-staff meeting because I guess it was mostly targeting direct care staff, you know, the nursing staff. And this all-staff training opened the door to all staff (dietary, the laundry, the housekeepers). So, they were all aware of [PAL Cards] now and even more so than what they had been … After that training and the opportunities to share with more people, I think it got the word out more, and more people were utilizing them.

In addition to engaging staff, champions were instructed to contact family members to act as proxies for residents who had difficulty communicating important preferences. Some families were enthusiastic about PAL Cards and readily provided information, while others were harder to reach. Provider 15 said:

We've got some [family] that thought [PAL Cards] were really great. Others that we called for information, [we] never heard back from them to complete the interview. So, it was kind of a mixed bag.

Executing referred to providers accomplishing the intervention according to plan. Providers who were most successful used organizational strategies, such as checklists, to ensure they were meeting project requirements. These providers also engaged staff and delegated tasks. Providers worked hard to overcome barriers to ensure they could meet requirements of the project. Provider 30:

I have a little checklist... I took it even months out so that way I could still keep tracking everything.

Champions reported Reflecting and Evaluating was also a positive facilitator to implementation. Throughout the project, providers reported frequently reflecting on PAL Cards and making changes based on their evaluation of implementation. Examples of changes made after evaluation included adjusting the frequency of PAL Card updates and offering different activities to better match residents’ preferences. Overall, staff described PAL Cards as a “learning process” and acknowledged the need to evaluate and adjust to successfully move the project forward. Provider 10 said:

I meet with a group of [employees] that have great things to say about it as well. They liked it. They really enjoyed it. They even said, "Can we take it further?" residents-wise, [with] the ones that are [able to put] up whiteboards in their rooms and different things, of what they like and what their days are going to be like. So, we've got a lot to look at. It kind of opened a whole new door for us.

The final Process code, Planning, had a valence of 0 (neutral). Overall, providers reported they did not do much planning for PAL Cards because the project was well organized and relatively straightforward, but lack of planning was not a hindrance to successful implementation. Primary planning efforts centered around the selection of residents who would participate in the intervention and mobilization of staff to complete PAL Cards. However, in hindsight, some providers expressed a desire for more comprehensive planning. Provider 15 said:

Looking back on it now, there should have been a meeting with my supervisor about deadlines, about clear goals of how many PAL Cards to be implemented—you know, monthly, weekly, however we wanted to do it.

This project evaluated the PAL Card QIP implemented in 26 NHs through qualitative analysis, based on two CFIR domains: Characteristics of the Intervention and Process. Overall, the adaptable nature of PAL Cards and positive impact of the intervention facilitated implementation. Providers were willing to adopt this QIP after hearing how it would help their communities (Evidence Strength and Quality). PAL Cards offered a better way to communicate preferences because they were portable and able to be personalized, and many providers did not already have a tool to communicate residents’ preferences, so PAL Cards filled this need (Relative Advantage). Barriers to implementation were Cost (eg, staff time to complete the project) and Complexity (eg, incorporating the PAL Cards into their work routines). Based on the findings, some barriers can be resolved through improvements to the PAL Card process, whereas others are characteristic of long-term care settings.

These findings add to the literature on the implementation of person-centered interventions in NHs within the QI context. Champions reported that getting other staff on board for creating and using PAL Cards was critical to the intervention’s success. Additional research on QI cites strong leadership support and teamwork among staff is key to successfully adopt QI initiatives in NHs.¹⁸ Providers used training sessions, regular staff meetings, educational pamphlets, and bulletin boards to get other staff involved in PAL Cards. While providers did receive all materials needed to conduct the intervention itself, it perhaps would have been beneficial for them to also receive promotional or educational material on the intervention that they could share with others in the professional community.

This study also supports the importance of flexible interventions through Adaptability and Trialability. CMS has identified flexibility as a key characteristic of successful QAPI,²⁶ and QIPs should be tailored to unique needs and capabilities of NHs.²⁷ PAL Cards were adaptable to the different needs of providers and residents, and the implementation could be adjusted based on available resources. Providers could also trial the project on a small scale at their community and decide whether scale up or stop the project. Providers could also decide which staff members would be involved with the project, which residents to start with, how long the interview should be, and where cards would ultimately be placed.

Providers reported the intervention was designed well and did not require advanced planning. Several participants noted that having the research team’s support was key to their success; this echoes earlier research that found external change agents helped providers problem solve.¹⁷ While it is positive that the intervention could be completed with little planning, this may also be problematic given the difficulty of sustaining QIPs in NHs. Some providers reported a desire to establish clear deliverables and timelines with supervisors to assist with prioritization. Going forward, more research is needed on strategies to sustain PAL Cards, since many efforts are de-implemented when external supports are removed.²⁸

Recreational activities are paramount in nurturing quality of life for NH residents.²⁹ Importantly, this study shows NH providers view PAL Cards as a valuable and flexible tool to communicate residents’ preferences. In the larger field of NH QI, researchers should be sensitive to the needs of providers and design adaptable, low-tech interventions. Strict protocols may not always result in provider success, given the wide range of available staff and resources present in NHs. Evidence-based interventions that are easy to adapt and demonstrate clear value may result in more widespread adoption. When promoting QIPs for NHs, support initiatives that have external coaches to provide valuable assistance and guidance.

Finally, the benefits of PAL Cards may help improve NH-level outcomes, such as a community’s five-star rating. The overall five-star rating is the average of three other ratings: health inspection, staffing, and quality measures. Honoring resident preferences has been suggested as a proactive approach to reducing the number of reports regarding resident care that a NH receives,¹⁰ which in turn could reduce deficiencies and improve the health inspection rating.⁹ Research has further suggested that NHs that implement more PCC often have better staff outcomes, such as satisfaction,⁷ which may reduce turnover and improve retention. Finally, PAL Cards prioritize quality of life by knowing and honoring resident preferences. While this may not directly address clinical quality outcomes, such as falls and injuries, residents are more likely to be engaged in the community when aspects of their care are tailored to their interests.30

This study has several limitations. Data related to implementation were collected only from providers who completed the project. Barriers to implementation may be better understood by studying non-completers. Additionally, data from this study came from a convenience sample of NH providers all located in the Midwest, due to funding constraints. Future research should prioritize studying implementation efforts in more diverse geographic locations, as other states may have policies and programs that impact PCC delivery. This study was conducted before the onset of the COVID-19 pandemic; therefore, the current staffing crisis must be taken into consideration when implementing novel initiatives. However, preference assessments are typically processes already built into workflow. The additional time consideration is approximately 22 minutes to create a PAL Card for each resident. The PAL Card template is user-friendly and tools for its implementation are freely available, including a 5:40 minute how-to video and one-page tip sheet to assist providers in creating PAL Cards. Finally, data from champions were self-reported, and they may have reported socially desirable responses.

Abby Hermesch MGS¹ • Miranda C. Kunkel LMSW² • Alexandra Heppner BSW¹ • Kimberly Van Haitsma PhD FGSA^3,4 • Katherine M. Abbott PhD MGS FGSA^1,2

Affiliations:

¹Scripps Gerontology Center, Miami University, Oxford, OH

²Department of Sociology and Gerontology, Miami University, Oxford, OH

³The Pennsylvania State University, Ross and Carol Nese College of Nursing, Program for Person Centered Living Systems of Care, University Park, PA

⁴The Polisher Research Institute at Abramson Senior Care, 5 Sentry Parkway East, Suite 100, Blue Bell, PA

Disclosure:

The authors report no relevant financial relationships.

Address correspondence to:

Miranda C. Kunkel
Email: corpormr@miamioh.edu

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Annals of Long-Term Care or HMP Global, their employees, and affiliates.