For a full description of the PE, see Appendix 9.
Aims and objectives
The purpose of the PE in this feasibility trial was to test and refine the theory of change underpinning the programme, and to explore how and what was delivered over time, the factors that contributed to and/or inhibited change and the programme’s feasibility and acceptability in a CH setting. A short summary is provided in this section, with full details in Appendix 9.
Methods
For full details, see Appendix 9, Methods.
All homes
In each home, the PE researcher observed care delivery during baseline to develop a picture of the care environment (≈ 5 hours per home). Completion of a purposely developed pro forma provided a snapshot of movement in both intervention and control homes at each data collection point; interviews were conducted with senior staff following the 9-month data collection period.
Intervention homes
The PE employed multiple methods to examine the process and content of MoveMore implementation as it evolved over time: observation and informant conversations with staff and residents during the preparatory and implementation phases (a total of ≈ 15 hours in each intervention home), analysis of audio recordings of workshop proceedings and documents (completed observations, action plans and reviews), qualitative interviews with implementation team members to explore the process of change over time and the factors constraining or facilitating this change, and conversations with residents.
Analysis
For full details, see Appendix 9, Analysis, Research team roles and relationships, A sensitising framework, and Implementation fidelity.
We employed an interpretive approach to analysis, using grounded theory methods of simultaneous data collection and analysis, constant comparison, searching for negative cases and memo writing.82
The NPT framework was used as a sensitising lens, with the aim of understanding the degree to which MoveMore may have become embedded in routine practice. Examination of fidelity to the intervention as intended was complicated by the dynamic nature of the CH environment, as well as the intended flexibility of the MoveMore programme. Adherence was thus to be explored across two levels: engagement of the implementation team with the workshops, and the reach of the programme beyond the implementation team to effect change at CH level.
Results
For full details, see Appendix 9, Findings.
Usual care
For full details, see Appendix 9, What is usual care?.
In the majority of homes at baseline (n = 9), staff showed meaningful knowledge of residents, which was reflected in their daily encounters with residents. Six homes adopted a consistently enabling approach in most tasks of daily living; in a further four homes, practice was inconsistent between staff: enabling in some tasks but not in others. In two homes, overall, practice was characterised as not enabling: it was ‘care done to’ individuals, often involving little or no encouraging talk. All homes adopted some flexibility with regard to some aspects of day-to-day practice. For those who were dependent on carer support to wash and dress, the degree of flexibility was constrained by staff availability. Overall, most care managers conveyed a general belief that ‘exercise’ and keeping ‘active’ was a ‘good thing’ to maintain residents’ well-being and to facilitate their engagement in social life. By contrast, the conception of movement as part of everyday life activities was not understood. Homes varied considerably in the opportunities available for engaging in social, leisure, and stimulating or meaningful activities. Not all homes had dedicated activity organisers (AOs) in post, and even those that did (three of five intervention homes and 5/7 control homes) varied in the level of resource available. Of those CHs without AOs, there were spontaneous short-interval activities (music and singalong, games, chair exercises) and organised medium-interval events using a combination of external resources [e.g. Music for Health (www.musicforhealthltd.co.uk/), exercise class] and CH staff (e.g. film nights, reminiscence). In all homes, care staff engaged in one-to-one pampering work (e.g. manicure) and there was access to a hairdresser/barber.
Intervention care homes
For full details, see Appendix 9, MoveMore implementation and Stages of implementation.
Intervention CHs were categorised as full, partial or failed implementers, depending on how far the CH progressed from exploring the programme through installation and initial implementation to full adoption, innovation and sustainability.
Full implementers
Two homes proceeded to full adoption of the programme (CH4 and CH5). Installation of MoveMore was pursued through participation in the workshops, and each step in the change process was taken back and enacted in the CH environment (observation); this was then reflected on in the subsequent workshop (action-planning) and the action plans that had been developed were tried out in the home and then reviewed (review and forward movement). In each case, action plans embraced action relating to individual residents, changes in the care environment and mechanisms to embed changes in care routines (incorporating movement in a review of the content of care plans, introducing systems for communicating action on movement, and training and supervision for all staff). These ‘full implementer’ homes had, during the period of the trial, moved a little beyond the stage of ‘full adoption.’ They had begun to harness the change process in such a way that it was feasible for them to embed aspects of change into their existing systems and procedures. This had the potential to embed movement in routine practice.
Although the process of implementation differed between the two homes and was affected by contextual factors, there were common features. These included strong, committed leadership to provide a steer to take the work forward; use of the observational tool among team members and in the wider staff group to engage staff in building a shared understanding of existing practice and what needed to change to enhance movement and extend the programme’s reach beyond the implementation team; and use of the implementation process to further multiple objectives.
Partial implementers
Two homes were ‘partial implementers’ (CH1 and CH3). Installation of MoveMore was pursued intermittently over a lengthy time span, including extended periods of inaction between participation in the workshops. First steps in the change process were taken back and enacted in the CH environment (observation) and reflected on in the subsequent workshop (action-planning). Some limited work was tried out with action plans in the home and then reviewed. CH1 proceeded in the direction of ‘full adoption’, although it did not quite attain it. In CH3, the focus of implementation was limited to action within the work spheres of the care staff who drove it forward; installation did not proceed beyond trying out one-off initiatives. Action was not pursued over time in either home, nor did action result in practice change at the CH level.
In CH1, contextual factors at the CH level resulted in other priorities taking precedence, and the absence of senior staff for prolonged periods during implementation meant that team members assumed different roles and relationships that negatively affected their capacity to steer the programme. A strategy to engage the newly appointed AO in the work of steering the programme and integrating movement in social and leisure activities was only partially successful: the post-holder was also in the process of developing the role and building relationships with care staff in relation to it. Overall, the intervention was conceived of as not ‘timely’ to implement in the context of what was happening in the home, albeit beliefs and intentions regarding its aims were sustained.
In CH3, at senior level, the conception of MoveMore as an intervention that necessitated joint work with staff to build a shared understanding of the value of movement, and to contribute to the work to make it happen, did not occur. Although individual care staff were enabled to pursue implementation within their own work sphere, active support to engage the wider staff team was not pursued.
Failed implementer
Care home 2 was a ‘failed’ implementer. Although three workshops were provided, what emerged over time was that implementation team members did not share an understanding of existing practice regarding ‘movement’ as a ‘problem’ that needed to be addressed. In particular, the nominal lead of the implementation team, although recognising that more could be done to reduce residents’ sedentary time, considered that existing systems were adequate to achieve this (senior staff mirroring good practice). Although individual care staff in the team held a contrary view, they lacked the legitimacy and power to take it forward. MoveMore was not understood as meaningful to pursue in terms of the knowledge, behaviour and actions required to implement it. In addition, contextual factors operating in this home resulted in a confluence of negative factors affecting care delivery.
