Development and evaluation of a Swiss nurse-led interprofessional care model for nursing homes

Health care delivery is changing, driven by technological, political, economic, and demographic trends. In OECD countries, the population aged 80 and over is expected to double from 4% in 2010 to 10% by 2050. As the population ages, the prevalence of chronic diseases and complex medical conditions increases, profoundly affecting the capacity of healthcare systems. Consequently, there is a growing demand for formal care in residential facilities, or nursing homes (NHs, as they are called throughout the dissertation), generating a rising demand for health care workers and increased spending. The average expenditure on long-term care is expected to rise from 1.3% of Gross Domestic Product to reach almost 3% for European OECD countries. Therefore, governments seek innovative, evidence-based care models for the geriatric population. These models should improve quality and, if possible, reduce the costs of care associated with frail older adults who have multiple chronic conditions––a demographic which currently drive healthcare costs to a large extent.
Internationally, evidence-based care models have been developed and tested, focusing on care models led by nurses with geriatric expertise. It is not surprising that interest is increasing in nurse-led care models. Constituting the biggest group of health professionals, nurses have a central role in care provision, spend the greatest amount of time with patients, and are well-positioned to contribute to health care by leading new care models. In such new care models, nurses are fully contributing members of the interprofessional team, leading the initiative to optimize the quality of care and life for residents by implementing evidence-based interventions to improve medical, transitional, and palliative care and to reduce unplanned hospital transfers. However, few of these nurse-led care models have been widely disseminated and implemented, and they cannot be easily applied in different contexts. Healthcare delivery systems worldwide are unique in their own clinical, economic, organizational, and cultural drivers and priorities. Thus, integrating, mixing, and adapting elements from these evidence-based care models differ across various contexts.
This dissertation seeks to address this gap and these limitations by applying specific implementation science principles to aid in the development and evaluation of a context-specific nurse-led care model for Swiss NHs. It includes a systematic and iterative approach to model development, ensuring that current evidence is reviewed, local model context is assessed and understood, and relevant stakeholders co-develop the model of interest. Once the nurse-led model had been implemented in eleven Swiss NHs, the researcher aimed to understand the implementation and its contextual factors based on care workers’ expressed views. The cognizance gained from the evaluation will deliver the knowledge of how the nurse-led model works in the real world, and will aid in the understanding of how to use strategies to implement the model into broader clinical practice so that current NH residents receive state-of-the-art care with proven efficacy. This dissertation is embedded in a national Swiss implementation science study of INTERCARE: “Improving INTERprofessional CARE for better resident outcomes”.
Chapter 1 gives a comprehensive overview of the NH landscape with its current challenges, focusing on avoidable hospitalizations as a quality issue. It presents evidence on effective international nurse-led care models that have successfully reduced hospitalizations.
Chapter 2 introduces the Swiss INTERCARE study as a context for this dissertation. The INTERCARE study uses implementation science methodology to develop, implement, and evaluate the contextually adapted nurse-led care model implemented in eleven Swiss NHs (called the INTERCARE model). Principles of the implementation science methodology are applied throughout the study description to provide the rationale for this dissertation using specific principles to develop and evaluate the contextually adapted INTERCARE model. Chapter 3 finally includes a discussion of the research gap, the rationale, and a description of the aims of this dissertation.
Chapter 4 reports on the first dissertation study, which takes a systematic and iterative approach with expert stakeholders to develop the competencies and outcomes of nurses in expanded roles (RNXs) to be included in the INTERCARE model. Based on evidence and knowledge from the contextual analysis, possible competencies and measurable outcomes for RNXs were formulated into a structured questionnaire survey. A group of national expert stakeholders completed a two-round rating process and participated in an in-person panel discussion using the RAND UCLA modified Delphi method. The study generated 190 competencies and 72 outcomes relevant to RNXs in the Swiss context.
Chapter 5 describes the results from three focus groups with lay stakeholders, i.e., residents and relatives from Swiss NHs. The focus groups explored residents’ and relatives’ experiences and needs in situations involving acute changes in residents’ health. The data revealed differences in perspectives regarding acute situations and care priorities between researchers, care providers, residents, and relatives. Alongside efforts to promote staff awareness of and responsiveness to acute situations, care staff must commit to learning about and meeting individual residents’ and relatives’ needs. Residents’ and relatives’ perspectives reshaped the INTERCARE model to incorporate their needs and not to solely concentrate on medical care to reduce hospitalizations.
Chapter 6 details the final mixed-method study presented in this dissertation. After implementing the INTERCARE model in eleven NHs, the researcher evaluated care workers’ response to the model elements used by care workers. A mixed-method study evaluated acceptability, feasibility, and uptake of the STOP&WATCH, ISBAR, and INTERCARE nurse role, as well as facilitators and barriers for their implementation. The quantitative results indicate that the ISBAR instrument and the INTERCARE nurse role were considered acceptable, feasible, and taken-up by over 70% of care workers. The STOP&WATCH demonstrated that the lowest acceptance included a total of 68% of participants, ranging from 24% to 100% across eleven nursing homes. A combination of factors, including the amount of information received, the amount of support provided in daily practice, the users' perceived ease of using the intervention and its adaptations, and the intervention's usefulness, appeared to influence the implementation's success. Two exemplary nursing homes illustrated context-specific implementation processes that serve as either barriers or facilitators to implementation. Both quantitative and qualitative findings are integrated using a complementary approach to explain the potential differences in intervention elements’ acceptability, feasibility, and uptake across the NHs.
Chapter 7 discusses and synthesizes this dissertation’s main findings, the methodological issues, along with the practical implications of this dissertation. It also puts forward recommendations for practice, policy, and future research. This dissertation bridges the research-to-practice gap in supporting the development of a contextually adapted, evidence-based nurse-led model corresponding with local resources and needs. By using principles of implementation science, it contributes to the literature and practice by evaluating the implementation of the nurse-led model from the care workers’ perspective to better understand the implementation challenges, including their determinants and solutions.