Sociodemographic characteristics of the participants
The sociodemographic and professional characteristics of the participants are visible in Table 2.
Categories
We identified eight main categories depicting inhibiting and facilitating aspects (see Fig. 2). A clear division into barriers and facilitators on the level of main categories was not possible. However, most of the factors describe barriers. Due to multiple obstacles during the implementation process, the introduction of sets of interventions was slowed down or postponed. This had a negative effect on the continuity of the implementation process. Subsequently, it was not possible to implement the multicomponent intervention of the specialized unit completely.
Main and sub-categories according to the i-PARIHS framework
In the following, we describe the main categories and the subcategories in detail.
Context: uncontrollable context-related changes
Contextual changes implied numerous interruptions during the implementation process. The participants’ answer to the question: “What comes to your mind when you think about the implementation process?” often was “interruption”. From the participants’ point of view, the reasons for interruptions were outside their control.
“We have already had so many interruptions with a detrimental effect. It’s nobody’s fault. But now we can no longer afford any interruption […]. Otherwise, everything silts up.” (Interview I13, pos. 62-64)
Consequences of the COVID-19 pandemic have slowed down the implementation process, shifted priorities and created uncertainty. The start of the implementation process was planned for spring 2020 – the time of the first lockdown. Pandemic-related measures resulted in a higher workload, restricted hospital access and changes in patient pathways. Establishing protection/isolation concepts and mastering the increased workload were at the centre of events. For a few months, the specialized unit for persons with cognitive impairment even accommodated patients who had to be isolated due to a COVID-19-infection.
During the implementation process, there was a staff turnover in the hospital management and on the unit (e.g., new CEO, maternity leaves, high fluctuation in the nursing team). Changes in the team structure resulted in a loss of knowledge, project-related continuity and motivation.
Context: “Straitjacket” of traditional hospital cultures and structures
According to the interviewees, the hospital culture is characterized by rigid structures and inflexible processes. The participants experienced this as a “straitjacket” severely limiting any development.
The majority of the participants regarded the environmental conditions as unfavourable for interventions addressing the needs of patients with cognitive impairment. The spatial structures of the unit resembled the traditional hospital architecture. Due to regulations, changes were impossible. For example, due to the architects’ specifications, signage for wayfinding could not be added or adapted, and no pictures or analogue clocks could be hung in the rooms. Additionally, the processes on the unit were designed around the workflow of the interprofessional team. They were highly synchronized and efficiency-orientated. Implementing patient-centred processes oriented towards the needs of persons with dementia (e.g., individualized schedules, extended time frames for care and therapy) was challenging. We were aware of the implementation barrier posed by efficiency-focused processes, but we were taken aback by the remarkable resilience and resistance to change exhibited for these processes. For example, tightly planned schedules made it almost impossible to extend a weekly interprofessional meeting by five minutes.
Furthermore, the participants reported economic maxims dominating the allocation of limited resources. The hospital operates as a stock company and as such is profit-oriented. The interviewees mentioned the hospital’s credo to achieve the billing code “geriatric acute care” for each patient. This economic necessity required a certain number of therapeutic sessions within a defined time frame. However, this was difficult to achieve for patients with cognitive impairment. Multiple appointments per day contradicts the needs of this patient group:
“There was the idea of working flexibly on the third floor. We treat nine patients and, depending on the necessity, one patient a little longer and the other patient for a shorter time. But that doesn’t work with this billing system. I’m afraid that this has to be said. It’s not feasible if you still want to achieve the billing code geriatric acute rehabilitation for all of them.” (Interview I6, pos. 46)
The participants experienced the environmental conditions and the economic maxims as inflexible and restrictive. From their point of view, an “individualization” of treatment and care – tailored to the needs of the person with cognitive impairment – is essential for the specialized unit. However, they pointed out that this is hardly possible within the existing organisational culture and the dominating economic requirements. Changing structures and processes (e.g., for interprofessional history taking) was part of the implementation plan. However, it was difficult to achieve due to the firmly entrenched organizational and professional culture.
According to the interviewees, the hospital management’s participation in the implementation process would have been decisive in order to promote structural changes. However, the participants mentioned that even for hospital managers it was difficult to question and to change traditional structures. From the point of view the interviewees, the hospital management behaved in an ambivalent way. On the one hand, they clearly decided in favour of introducing the specialized unit. On the other hand, they did not bring in their authority into the implementation process. Members of the project group also critically reflected that they did not succeed in getting the hospital management “on board”.
Recipients: scepticism towards a specialized unit
Professionals working on the specialized unit were sceptical regarding the specialization for patients with cognitive impairment. They also did not know the content of the components of the specialized unit in detail. This caused uncertainty and doubts about whether it would be possible to care for patients with dementia and delirium in one unit:
“I’m basically questioning it. I think we would have to discuss this again in principle. To what extent does it make sense to separate these people? […] Certainly, there are reasons why we should bring them together. But there are also many dangers ….” (Interview I12, pos. 83).
Many participants expressed their apprehension concerning the burden for the team due to the high intensity of care. Furthermore, the interviewees emphasized that the combination of patients with and without cognitive impairment resulted in different care needs. From their point of view, there is a danger of overseeing the needs of patients without cognitive impairment. In contrast to persons with dementia, they communicate their needs in a way that is less visible and audible. The participants mentioned that they cannot “do justice” to all patients and, therefore, experience an ethical dilemma.
Furthermore, the interviewees also expressed uncertainties about the components of the specialized unit. The concrete meaning of “specialization” was unclear to them and they did not know the targeted patient group. In addition, the roles and distribution of tasks in the therapeutic late shift were unclear for the participants. According to them, conception and communication towards the staff were insufficient. Therefore, they felt uncertain and did not implement the interventions:
“My question is: What is the task for me as a physiotherapist in the late shift? Is it caring for the person? Or is it more a therapeutic activity? In physiotherapeutic terms, I think there is an extremely wide scope.” (Focus group 1, P3, pos. 22)
Recipients: insufficient resources
From the participants’ point of view, caring for patients with cognitive impairment is time-consuming and requires individualized schedules. However, the staffing situation on the specialized unit did not differ from other units. The specialized unit included plans for increased staffing in the nursing team and ongoing staff education. Unfortunately, due to high turnover rates, the enhancement in staff numbers could not be implemented. This prevented the professionals from implementing innovations in general and complicated caring for patients with cognitive impairment in particular. The plan to create additional jobs for nurses proved to be unrealizable, due to lack of applicants for these jobs.
According to the participants, the lack of time resources was the result of the tense staffing situation in the nursing team:
“I think that the staffing ratio must be high enough. Now it is otherwise … It is neither fair to the patients nor to the nursing staff. Actually, everyone is overburdened” (Interview I6, pos. 74).
A high demand for care occurred particularly in the late afternoon, in the evening and at night when the staffing level was very low. The participants reported being unable to meet the patients’ needs during these times. This resulted in situations prone to complications:
“We often have patients with hip transplant. They walk around as if nothing had happened. And that is sometimes a bit difficult for us (laughs).” (Focus group 1, P4, pos. 50-51)
The COVID-19 pandemic, high demands on nurses and continuing uncertainty, resulted in a high number of resignations. In addition, there were also several maternity leaves. The remaining team struggled to maintain regular patient care. Exceptional patient situations triggered fear and rejection:
“I find it difficult when we have more than two patients [with an increased need for care]. Then you need more hands to take care of them. When someone constantly calls: ‘Hello!’ … And we’ve really had a lot of [nurses] saying: Maximum one [with an increased need for care]. Due to the burden … And the young [nurses] say: I don’t like it anymore! We had [a patient] who was really so prone to falling … We had to accompany her everywhere. You couldn’t leave her alone for a minute. Otherwise, she left the unit. You reach the limit.” (Interview I8, pos. 12-13)
During the pandemic, implementation activities were postponed and beds on the unit were blocked. Subsequently, the stress levels in the nursing team were more closely monitored and taken seriously. Stabilization in the nursing team had a higher priority. However, implementation activities were further delayed.
Innovation: lacking conceptual clarity
Participants mentioned ambiguities and vagueness concerning the term “specialized unit for patients with cognitive impairment”. The intention was to address patients with dementia and delirium. The term “cognitive impairment” should signal that the unit is not exclusively for patients with dementia – it is also open to other patients. However, this complicated the triage. The interviewees reported that the triage should be aligned to the current occupancy situation of the specialized unit. Due to this, it was left to the interpretation of the professionals which patients to treat in the specialized unit:
“I think it’s fair to say that we have a unit for ‘patients with dementia’. I mean, that’s not a personal judgement. It’s a diagnosis. And now you have to say: We have a ‘unit for patients with cognitive impairment’, I think that is a trivialization! Eighty percent of our people have less than twenty-six points in the Mini Mental State Examination” (I12, pos. 12).
According to the participants, the aim of the newly introduced “extended therapy service” was unclear. Originally, it was planned to make schedules more flexible and to ensure a more even distribution of therapies during the day. For example, therapy sessions for patients with dementia, that could not follow an entire therapy session could be split in two shorter sessions and provided over the course of the entire day. However, the participants reported that they did not know whether therapy should now take place preferably in the late afternoon hours. Additionally, it was not clear, whether this service is focused on care or on therapy.
Facilitation: neglected communication
Retrospectively, the participants considered it as crucial to have a viable communication strategy:
“We never agreed upon the question: How should we inform the persons involved? We should have definitely agreed on that at the beginning: Who informs whom and when? And who is responsible for what?” (Interview I13, pos. 48)
The participants characterized the communication as unsystematic, sparse and delayed. It can be concluded that the communication measures proved insufficient, despite the team’s already extensive efforts to boost communication through various means, including regular informational events for all employees and ongoing presence in management committees. The initial plan to appoint a dedicated study nurse for the specialized ward to enhance communication among stakeholders and teams fell through due to the inability to fill the position. The communication deficits concerned all persons involved: members of the project group, staff, and hospital management. According to the interviewees, communication within the project group mainly took place in the workshops organized by the researchers. However, the workshops were initially not intended as the central medium of communication. To fulfil this function, more frequent workshops with shorter intervals would have been necessary. The members of the project group recognized the shifted function of the workshop. However, they did not react on it and workshops were held as planned. Outside the workshops, communication was unsystematic, random and spontaneous. The participants mentioned that the project group neglected communication about roles and process design. For example, there was no information about role clarification and about the facilitator role. As a consequence, role interpretations were very inconsistent.
At the beginning, the project group defined the tasks of implementers and co-researchers. However, in the course of the further project, there was no ongoing discussion concerning their tasks. Everyone assumed to know role-associated tasks. No one noted the necessity of increased role clarification. Inconsistencies only became apparent when the implementation was already far advanced. At this point of time, it was impossible to resolve the inconsistencies.
According to the interviewees, communication with the hospital management was primarily information-related. The project leader informed the management on a regular basis about the implementation progress. However, the management was never actively engaged in the project. From the participants΄ point of view, this was a a barrier. Neither specific needs nor responsibilities were addressed.
Communication towards hospital staff was limited to information events. However, these events were seldom and took place rather late. Some respondents were of the opinion that this inhibited implementation. The project “petered out” (Interview I1, pos. 11). Interestingly, not all project group members held this view.
Another hindering factor was associated with new team members. There was no strategy for introducing new colleagues to the multicomponent intervention of the specialized unit.
Facilitation: motivation and change competence
The motivation to create change and to improve change competence varied among project group members. According to their profession, they had different opinions concerning the need for change. Nurses reported that their situation on the unit before the implementation was stressful and frustrating. They were confronted with an overwhelming workload. Therefore, they pushed for change. However, there was no uniform opinion among members of the nursing profession.
The project group members’ change management skills varied. This may be caused by different professional functions and by their various standing in their team. Whereas some project group members had leadership roles, others had no leadership experience at all. Therefore, recognizing the need for action and creating change proved to be difficult for them:
“You need certain leadership skills if you want to share your knowledge with your teams. This is something I will certainly consider in future interprofessional projects. It’s not only about a certain the topic. You also have to think about which people you want to include and what is their standing in the team. I think, we should have asked this question at the beginning.
But in the course of time, certain people were replaced. And then these considerations were no longer in the foreground”. (Interview I16, pos. 30)
Change management skills were relevant for the selection of project group members. However, due to staff turnover, the project group members changed. The successors often did not meet the originally defined selection criteria:
“Planning such long-term projects is always very difficult. You have consider that there can always be changes – even in key positions. Identifying the right people at the right time – that is extremely difficult. And I think it is also difficult to define a replacement for each function in advance.” (Interview I16, pos. 60)
Synthesis
Footnote 1
: fragmented interprofessionalism
According to the participants, treatment and care of persons with cognitive impairment require close cooperation between the professions involved.
On the one hand, the interviewees emphasized that interprofessional collaboration is common in their clinical practice. The already established interprofessional culture in clinical practice facilitated the implementation. On the other hand, outside clinical practice, there was limited experience of interprofessional collaboration at the project level. One participant emphasized that this project was the first “big interprofessional project” (Interview I16, pos. 12) in the course of many years. It became apparent that the staff was strongly rooted in a monoprofessional culture. The habitus significantly influenced the way in which interprofessionalism was lived. For example, in nursing and in the medical profession, it is customary to cover shifts 24-hours seven days a week. However, therapists were not used to working later than 5 pm. Subsequently, they responded with high resistance to the introduction of a therapeutic late shift.
The professional habitus also influenced the interpretation of one’s role in the project group. Nurses expressed that they felt responsible for the implementation and the steering of implementation activities. They considered it as important to ask questions and to reflect their action. One nurse described the nursing role und thereby the habitus, as “the mommy for everyone” (I13, pos. 88). Physicians emphasized the personal responsibility of every individual professional with regard to the implementation:
“We should implement that officially – we have all the instruments. […] And I would like to proceed pragmatically […]. We all have self-responsibility […]. The roll-out of the individual parts should be left to on one’s own initiative” (Interview I15, pos. 2)
According to the participants, the interprofessional composition of the project group facilitated the implementation. There was one representative of each profession – except for nursing with two clinical representatives and two research representatives. The participants critically reflected the predominance of nursing. Nursing was the profession with the highest contribution of resources, including staff and decision-making-power. On the one hand, this was related to the nurses’ high psychological strain in caring for persons with cognitive impairment. Due to this, the motivation for change was very high on the part of project group members of nursing profession. On the other hand, the majority of the interprofessional team consisted of nurses. The participants mentioned the nursing focus of the multicomponent intervention of the specialized unit and of the implementation:
“It is still rather too nursing-oriented. […] The initial concept is like this … Each profession only works side by side. I would like to see togetherness.” (Interview I14, pos. 106)
The multicomponent intervention included some sets of interventions affecting all professions involved. However, other sets addressed only one profession, for instance the management of somatic diseases and the nursing process. Subsequently, the multicomponent intervention unintentionally promoted working alongside each other rather than with each other.
In addition, entrenchment in one’s own profession became apparent in differences of professional language and concepts. For example, one set of interventions addressed communication with family members. The denomination of this set was widely accepted in nursing but not in the area of social work. Accordingly, social workers did not identify themselves with this set of interventions. Although the project members work together every day, they were not aware of different terminologies.
The participants experienced the cooperation with researchers as a facilitating factor. They cherished especially the workshops during the implementation process, introduced by the researchers as part of the action research cycle. In the workshops, they elaborated the sets of intervention in detail, developed implementation strategies and evaluated the ongoing implementation activities.
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