The Wellness Hub Program: Design of a theoretically-rooted support strategy to leverage facilitators and overcome barriers facing Long-Term Care and Retirement Homes in Ontario during the COVID-19 pandemic

doi:10.21203/rs.3.rs-4752265/v1

Background

Long-term care and retirement homes (LTCH/RH) faced systemic challenges that were exacerbated by the COVID-19 pandemic. Following a comprehensive needs assessment with 91 LTCH and RH leaders from 47 LTCH/RH in Ontario, Canada, we identified three major challenges facing homes: infection prevention and control (IPAC), vaccine confidence and uptake, and staff well-being. We aimed to co-create an evidence-based, theoretically-rooted support program titled the Wellness Hub to support LTCH and RH to navigate real-time challenges.

Methods

We identified evidence-based interventions to address identified LTCH/RH challenges, which included: IPAC protocol implementation, COVID-19 vaccine uptake among staff in accordance with Canadian public health guidance, and a well-being program to support staff mental health and wellness. We used the Knowledge to Action model to guide Wellness Hub program development. Barriers and facilitators to implementation were mapped to the Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR). Implementation strategies to address barriers and leverage facilitators were identified via a process of co-creation with LTCH/RH stakeholders and guided by the COM-B rooted SELECT tool and the CFIR-ERIC mapping tool.

Results

Twelve TDF domains and 18 CFIR constructs were identified as barriers and/or facilitators to implementation, reflecting the complexity of challenges facing homes during the pandemic. Via the SELECT tool, we identified six intervention functions and 14 implementation strategies to target individual-level change. An additional four strategies for organizational and systems-level implementation change were identified via the CFIR-ERIC mapping tool. The following implementation strategies were used to facilitate implementation of our evidence-based practices: town halls, implementation coaches, promotion for LTCH/RH wellness days, creation of infographics and educational resources (including an open-access resource repository), a weekly newsletter with LTCH/RH directives, a vaccine champions program and e-learning course, modelled change, an IPAC-self-assessment tool, seed funding, vaccine incentives, access to off-site COVID-19 testing, monthly community of practice meetings and use of opinion leaders.

Conclusion

We demonstrate the use of implementation science methods to rapidly address real world, real-time problems. Our methods and protocols provide a blueprint for rapidly engaging LTCH/RH communities to co-create and implement a comprehensive, multipronged program during health emergencies.

Trial Registration

: https://osf.io/hkfae

real-world problems

implementation science

implementation practice

co-creation

long-term care

Long-term care and retirement homes were challenged to implement evidence-based practices to meet their needs during the height of the COVID-19 pandemic.
We show how implementation science methods can be leveraged to co-create an evidence-based, theoretically-rooted program that is responsive to home needs.
Use of a co-creation approaches allowed us to identify and address needs (e.g., staff mental health and well-being challenges) that would have otherwise gone overlooked
Our study provides a blueprint for leveraging implementation science methodology to address real-time implementation practice gaps during widespread health emergencies.

Long-term care homes (LTCHs) and retirement homes (RHs) have consistently faced systemic challenges related to staffing shortages, funding constraints, outdated infrastructure, and lack of standards and regulatory policies [1]. Wong et al. estimated that over $20M (CAD) between 1998–2020 were dedicated to commissioning over 80 reports to describe challenges and recommendations for Canadian LTCH [2]. Despite these well-known challenges, little had been done to address systemic gaps in LTCH/RH. It was in this context that the COVID-19 pandemic struck, creating an unparalleled crisis for Canadian LTCH/RH.

In 2020, COVID-19 deaths in Canadian LTCH/RH were significantly higher than any other nation, estimated at 81% compared to 31% in the United States and 27% in Australia [3]. The province of Ontario was especially hit hard, due to gaps in coordination between homes, public health units and hospitals, more shared rooms, fewer care hours for residents, fewer resources and less oversight into care processes [4].

We aimed to develop a support program to address LTCH/RH needs during and beyond the COVID-19 pandemic. Our study was guided by the Knowledge to Action (KTA) Cycle, a process model that outlines the stages of implementing evidence that was developed following a synthesis of over 30 planned action theories [5]. At the center of the KTA is the knowledge synthesis funnel, which emphasizes the importance of rooting implementation interventions in evidence, and developing accessible and useful knowledge tools and products (e.g., infographics, educational materials) that summarize evidence to support its use in practice. The outer cycle of the KTA outlines the stages of implementing this evidence. The seven stages include: Stage 1-Identify the problem/Determine the know-do gap/Identify, review and select knowledge; Stage 2-Adapt knowledge to local context; Stage 3-Assess barriers and facilitators to knowledge use; Stage 4-Select, tailor and implement interventions; Stage 5-Monitor knowledge use; Stage 6-Evaluate outcomes; and Stage 7-Sustain knowledge use. The purpose of this manuscript is to describe our efforts to assess barriers and facilitators to knowledge use (Stage 3) and select, tailor and implement interventions (Stage 4).

In a previous manuscript, we outlined our findings corresponding to Stage 1 of the KTA [6]. With the goal of supporting LTCH and RH to navigate the COVID-19 pandemic, we conducted an in-depth needs assessment with leadership across 33 LTCH and 14 RH in Ontario, Canada to identify the needs and challenges facing homes [6]. The intent was to gather real-time information and co-design an evidence-based, theoretically-rooted support program for Ontario LTCH/RH. While we anticipated that most concerns would be related to infection prevention and control (IPAC) and staffing shortages, our interviews revealed that this was only one piece of the puzzle [6]. Through 91 needs assessment interviews conducted with home leadership, we identified challenges broadly relating to three categories: 1) leaders were challenged to implement IPAC protocols and measures; 2) leadership needed supports to facilitate COVID-19 vaccine access and promote vaccine confidence among staff and residents; and 3) leadership needed supports to address the significant well-being and mental health challenges experienced by frontline staff. Following this needs assessment, we developed an evidence-based, theoretically-rooted, tailored program, called the Wellness Hub, to support LTCH and RH to navigate the COVID-19 pandemic and its related challenges. We included three implementation practices within this program. First, we aimed to support the implementation of IPAC practices in keeping with Public Health Ontario’s IPAC Checklist for Long-Term Care and Retirement Homes [7]. Second, we aimed to promote vaccine confidence and uptake in keeping with the Government of Canada’s COVID-19 vaccine immunization guide and the Ontario Government’s mandates for all LTCH/RH staff to receive two SARS-CoV-2 vaccines followed by at least one booster dose [8]. Third, we aimed to provide mental health and well-being resources that staff could use to support their individual well-being, in addition to supports for LTCH/RH leaders to promote well-being among residents and staff. Additional details on the preliminary work used to identify these practices is outlined in Appendix 1.

Once the evidence-based interventions to address home needs were identified, we used implementation methodology to design a multipronged implementation strategy to deliver these interventions to Ontario LTCH and RH. In this manuscript, we describe the process of developing the Wellness Hub program implementation strategies.

Our study objectives were as follows:

Map identified barriers and facilitators to theoretically-rooted implementation frameworks to identify corresponding strategies to support evidence-based implementation of IPAC, vaccine, and well-being interventions to LTCH/RH

Describe the components of the Wellness Hub program identified via theoretical mapping and co-creation with LTCH/RH stakeholders

Preliminary Work

Appendix 1 outlines our work for KTA stages 1 & 2 – Identify the problem, Determine the know-do gap, Review and Select Knowledge, Adapt knowledge to local context. Using a co-creation process that engaged LTCH/RH staff and leadership, academics, clinicians, policymakers, caregivers and non-profit health and long-term care organizations, we identified evidence-based interventions corresponding to the gaps related to IPAC adherence, COVID-19 vaccine uptake, and staff well-being. Where applicable, we report our methods and findings using the Template for Intervention Description and Replication checklist (TIDieR) (Appendix 2) [9].

Assessing Barriers and Facilitators to Knowledge Use

We identified barriers and facilitators to the implementation of Public Health Ontario’s IPAC Checklist for Long-Term Care and Retirement Homes (practice 1); vaccine confidence and uptake, as aligned with the Government of Canada’s COVID-19 vaccine immunization guide and the Ontario Government’s mandates for all LTCH/RH staff to receive two SARS-CoV-2 vaccines followed by at least one booster dose (practice 2); and mental health and well-being resources to support LTCH/RH staff and leaders (practice 3)[7,8].

The barriers and facilitators were identified via semi-structured interviews with 91 LTCH/RH leaders. Interviews were conducted using a rapid analysis approach and took place between February 2021 and July 2022 [10]. Detailed methods and interview findings are reported elsewhere[6]. We identified a total of ten, six, and two barriers related to implementation of interventions to address IPAC, vaccine access and uptake, and well-being challenges, respectively. We also identified 13 themes pertaining to facilitators or implementation strategies used to address these barriers, although the prevalence and use of these strategies varied considerably by home. A full list of the identified barriers, facilitators and implementation strategies are reported elsewhere[6].

To categorize the identified barriers and facilitators, we used the framework approach, which is an analytical method that provides a series of steps to guide qualitative analysis and is commonly used in implementation science studies [11]. First, study staff transcribed the key informant interviews and familiarized themselves with the transcripts and accompanying notes taken during the interviews. Next, we developed coding frameworks rooted in implementation science frameworks to guide the categorization and analysis of our data. The frameworks included the Theoretical Domains Framework (TDF), a meta-framework of over 30 behavioural psychology theories describing barriers and facilitators to individual change and the 2009 Consolidated Framework for Implementation Research (CFIR), a meta-framework that outlines five domains (Intervention characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Process) that impact implementation [12,13]. We used the TDF to categorize barriers and facilitators at the individual level and the CFIR to categorize barriers and facilitators at the organizational or systems level.

Three researchers (KQL, ET, LS) independently categorized barriers and facilitators using the TDF and CFIR frameworks. Data were double-coded by at least two researchers. Any coding discrepancies were discussed and resolved using a consensus process. One researcher (KQL) reviewed the coded data to identify the TDF and CFIR domains requiring intervention in order to mitigate barriers and leverage facilitators to implement IPAC, vaccine, and well-being supports. This researcher then conducted intervention mapping, a theoretically-rooted procedure of matching identified barriers and facilitators with corresponding evidence-based strategies that can be used to mitigate barriers or leverage facilitators. Mapping was conducted by an experienced research coordinator (KQL) and reviewed by a research manager (JMB) and implementation scientist (CF).

Select, Tailor and Implement interventions

To map barriers and facilitators identified using the TDF, we utilized the SELECT tool, as outlined in Fahim et al.’s practicing knowledge translation workbook[14]. The SELECT tool combines Michie et al.’s guidance on how to integrate use of the TDF with the COM-B behaviour change wheel (a behaviour change theory that provides individual and system-level strategies to facilitate change) to identify the types of strategies (known as intervention functions) that can be used to bring about change [14,15]. The tool then provides examples of strategies within each intervention function, using guidance from Cochrane Effective Practice and Organization of Care framework and reviews [16]. All strategies corresponding to TDF barriers identified via the SELECT tool were retained as potential options to facilitate implementation. CFIR barriers and facilitators were mapped to corresponding expert-endorsed strategies using the CFIR-ERIC mapping tool, which guides users to select strategies [17]. CFIR-ERIC strategies with endorsements greater than 50% endorsement were retained as potential options for implementation [18].

Implementation strategies were selected and operationalized in partnership with LTCH/RH stakeholders using a) the feedback on utilized or suggested strategies directly received via the key informant interviews; b) input from our study steering committee; and c) our report on barriers, facilitators and recommendations to long-term care COVID-19 IPAC preparedness and response, commissioned in 2020 by Healthcare Excellence Canada [19]. The report included a secondary analysis of 25 interviews with LTCH and RH stakeholders from across Canada to identify barriers and facilitators related to six IPAC COVID-19 challenges facing LTCH, as well as identified IPAC needs, opportunities and recommendations. The results of this report are available elsewhere [19].

Barriers and Facilitators Mapping to Theoretical Domains

In a previous study, we identified specific barriers and facilitators related to IPAC (Table 1), vaccine (Table 2), and well-being support implementation (Table 3) [6]. Tables 1–3 outline our mapping of these barriers and facilitators to relevant TDF domains and CFIR constructs. Twelve TDF domains were identified via mapping; the majority of implementation determinants were categorized as both a barrier and facilitator, depending on the context of the home. An additional 18 CFIR constructs were identified as organizational and system-level barriers and facilitators. Notably, the CFIR constructs of partnerships and connections, relationship connections, communications, culture (recipient centeredness), and external pressures related to performance management were only identified as facilitators, highlighting the importance of external supports and partnerships (e.g., hospital hub and spoke systems) to homes during the pandemic (Tables 1–3).

Identification of Corresponding Strategies

Via the SELECT tool, we mapped TDF barriers and facilitators to Michie et al’s Behaviour Change Wheel Intervention Functions as shown in Table 4 [14, 15]. The following intervention functions were identified as potential interventions to mitigate barriers and leverage facilitators: Modelling (addresses 7 domains); Education and Enablement (address 6 domains); Persuasion and Training (address 5 domains); Environmental restructuring (4 domains); Coercion and Incentivisation (3 domains), and Restriction (2 domains).

The following implementation strategies were selected to facilitate behaviour change, mainly at the individual level: Conduct educational meetings, distribute educational materials, use champions, develop a community of practice, prepare LTCH leadership and staff to be active participants, secure public funding and contracting, alter payments to health workers, change service sites, offer incentives, model and simulate change, identify and use opinion leaders, use mass media, conduct local consensus discussions, and conduct educational outreach visits. A number of additional strategies were suggested for individual homes, which allowed for tailoring based on needs (e.g. suggestions to audit and feedback IPAC adherence and vaccine uptake).

Using the CFIR-ERIC mapping tool, we identified four strategies with an endorsement percentage greater than 50% for the identified CFIR domains. These included: conducting educational meetings, developing educational materials, distributing educational materials and accessing new funding. Additionally, 32 strategies had a cumulative percentage of greater than 50 (meaning that they could be used to address multiple barriers and facilitators). All of these strategies demonstrated overlap with strategies identified via the TDF and were thus selected to facilitate change across the individual and organizational levels.

Development of the Wellness Hub Support Strategy

We combined all identified strategies into a comprehensive, tailored support program called Wellness Hub. Table 5 outlines the components of the support program and their correspondence with the TDF domains and CFIR constructs. Thus, to support IPAC implementation (i.e., adherence to the IPAC checklist, use of polymerase chain reaction saliva testing with rapid results); vaccine access and uptake (i.e., adherence to Ontario and Canada guidance on COVID-19 vaccinations); and well-being support implementation (i.e., acknowledging the mental health and well-being impacts of the pandemic and provide corresponding supports), we created the following implementation strategies: town halls, implementation coaches, promotion for LTCH/RH wellness days, creation of infographics and online/printed educational resources, creation of an open access resource repository, weekly Wellness Hub newsletter, vaccine champions program and e-learning course, coaching staff leadership on how to model change, IPAC self-assessment tool, access to $10,000 in seed funding to put towards pandemic-related needs (through our partnership with Healthcare Excellence Canada), vaccine incentives, access to off-site COVID-19 testing, monthly community of practice meetings, and use of opinion leaders [20]. Additionally, we provided participants with an opportunity to participate in a research study that allowed them to learn of their COVID-19 antibody status. Throughout, we utilized an integrated, co-creation approach to support strategy design and implementation, and allowed tailoring based on the needs of each home. Finally, we were able to leverage two strategies external to our program to facilitate change: COVID-19 vaccine mandates imposed by the Ontario government (required all LTCH/RH staff to receive two doses and one booster dose of a COVID-19 vaccine), and access to the Ontario hub-and-spoke model, which partnered LTCHs with hospitals to facilitate case control management and IPAC implementation.

The COVID-19 pandemic placed unprecedented stress on the long-term care and retirement home sector that was already facing a myriad of challenges [21]. We conducted an in-depth needs assessment with 47 LTCH and RH in Ontario to identify needs related to IPAC guideline implementation, COVID-19 vaccine access and uptake, and mental health and well-being challenges among LTCH/RH staff. Guided by the KTA cycle, we identified interventions to address each of these challenges. Using a qualitative rapid analysis approach, we identified a total of ten, six, and two barriers related to implementation of interventions to address IPAC, vaccine access and uptake, and well-being challenges, respectively, and 13 themes pertaining to strategies or facilitators to address these barriers [22]. We mapped these barriers and facilitators to theoretical frameworks, identifying 12 domains on the TDF and 18 constructs on the CFIR. We used a theoretically-rooted, evidence-based intervention mapping process to identify potential strategies to mitigate barriers and leverage facilitators. Via a co-creation process and input from our multidisciplinary steering committee, we developed the Wellness Hub LTCH/RH support program, which included 14 implementation strategies.

COVID-19 placed a spotlight on LTCH/RH, yet the literature is limited in terms of programs that leveraged implementation science and co-creation methodology in order to develop a supportive, responsive and tailored program. For instance, a systematic review by Byrd et al. identified interventions and policies in long-term care during COVID-19 [23]. The authors found that half of the 137 studies identified across 22 countries were focused on COVID-19 IPAC. Otherwise, these studies aimed to improve access to healthcare, many with a focus on resident-targeted interventions [23]. Fewer studies aimed to explore the experiences or supports available to LTCH/RH staff or leadership, who experienced significant added pressures posed by the pandemic [24].

Implementation experts called for the use of implementation science to address ‘real-world, real-time’ problems during the COVID-19 pandemic, arguing that rapid and novel methods are needed to implement novel evidence to address urgent problems [25]. However, the urgency of the pandemic does not afford us the opportunity to design and conduct large-scale experimental studies; for instance, in our setting, home needs were so great and so urgent that home leaders did not have the willingness or capacity to participate in research. Instead, leaders highlighted the need for support programs that posed minimal burden to them and their staff. We utilized a co-creation approach to identify these needs and applied rapid methods to established implementation science methods to swiftly develop a multi-pronged support program that was responsive to evolving needs and allowed for tailoring to individual homes. Our methods align with other implementation researchers during COVID-19; for example, Fontaine et al. describe a seven-step methodology for conducting community-based behavioural science research, rooted in identifying community partners and priorities, building trust, tailoring to user needs, and use of an iterative and responsive approach [26].

We recommend the application of such an approach to future emergency situations and suggest a number of strategies to facilitate its use. First, establishing trust and mechanisms for routine community engagement was critical to facilitate the rapid development and implementation of our program. Second, we aimed to share our methods and processes in a manner that reflected the iterative and adaptive nature of implementation during a health emergency. Thus, rather than publishing our study protocol in a journal, we chose to publish our protocols on Open Science Framework, which allowed us to iteratively update our methods, approaches and strategies in response to evolving home needs [27]. Third, we worked closely with our research ethics board to develop innovative approaches to minimize burden of participation via the use of streamlined, accessible consent processes, minimal data collection burden, and approvals for use of an iterative and flexible implementation approach.

Our study has limitations. First, our program was limited to LTCH and RH in Ontario, the majority of which were in the Greater Toronto Area, and thus may not reflect the needs and experiences of LTCH and RH in other regions. Second, while this study was co-created with diverse stakeholders, including patients, caregivers and community organizations, our interviews were limited to LTCH and RH staff, and did not include LTCH residents. This decision was made given the COVID-19 restrictions in place limiting in-person engagement within homes, and to minimize burden on LTCH and RH staff supporting study recruitment. Finally, our analysis of contextual barriers and facilitators used the original 2009 version of the CFIR; the updated version of the CFIR was released once our analysis was already underway [28].

We demonstrate the use of implementation science methods to rapidly address real-world, real-time problems. Our methods and protocols provide a blueprint for rapidly engaging LTCH/RH communities in order to co-create and implement a comprehensive, multipronged support program that addresses real-time challenges and offers evidence-based strategies for mitigating and overcoming these challenges faced during health emergencies.

CFIR

Consolidated Framework for Implementation Research

COM-B

Capability-Opportunity-Motivation Behaviour Change Wheel

ERIC

Expert Recommendations for Implementing Change

IPAC

Infection prevention and control

KTA

Knowledge to Action Cycle

LTCH/RH

Long-Term Care Homes/ Retirement Homes

TDF

Theoretical Domains Framework

Ethics approval and consent to participate:

This study received ethics approval via the Unity Health Toronto Research Ethics Office (REB # 20–347). All study participants provided consent to participate.

Consent for publication:

Not applicable

Competing interests:

The authors declare that they have no competing interests.

Funding:

This study was funded by the COVID-19 Immunity Task Force (2021-HQ-000143), the Ministry of Labour, Training and Skills Development, and the Canadian Immunization Research Network (SH18.ON45).

Author Contribution

CF, KQL, AT, SES conceptualized this study and developed the study protocol and materials. CF, SES and JMB oversaw all aspects of study conduct including recruitment, data collection, analysis, and interpretation. KQL, VB, JF, CG, VG, ATH, AM, TO, AT, and HJCG supported data collection and data analysis. KQL, ATH, ET, LS, and CF coded themed study data using theoretical frameworks and KQL and CF mapped theoretical domains to corresponding implementation strategies. CF, KQL, VB, JF, CG, VG, ATH, AM, TO, NP, LS, AT, ET, HJCG, JMB and SES developed the Wellness Hub support program and refined it using feedback from LTCH stakeholders. CF, KQL, JMB, ATH, and SES drafted this manuscript; CF, KQL, VB, JF, CG, VG, ATH, AM, TO, NP, LS, AT, ET, HJCG, JMB and SES revised the work and approved the submitted version.

Acknowledgement

The authors would like to thank Theresa Ikpeni for supporting this work. The authors would like to thank all of the Wellness Hub partners (wellness-hub.ca) and LTCH/RH homes and staff who participated in this study.

Availability of data and materials:

Our manuscript has no associated data.

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Table 1

Barriers and Facilitators to IPAC uptake, coded to TDF and CFIR
Barrier	Description of Theme	TDF Domains	CFIR constructs
Delivering IPAC education in the LTCH setting was time consuming, resource intensive	Educating staff on IPAC measures was very time consuming and resource intensive, as leadership had to adapt standard IPAC education to the context of the COVID-19 pandemic and outbreaks.	• Environmental Context and Resources • Knowledge • Memory, Attention and Decision Processes • Behavioural Regulation	• Compatibility • Available resources (access to knowledge and information)
Staff did not implement IPAC guidance consistently	Sites experienced inconsistent implementation of IPAC protocols from their staff, such as not always social distancing, not maintaining consistent hand hygiene, and irregularity with how staff wore PPE.	• Intentions • Behavioural Regulation
Residents with limited capacity were not able to follow IPAC protocols	Staff have experienced challenges with ensuring residents with dementia are following IPAC protocols. There were challenges around keeping PPE on residents with dementia, ensuring that they maintained hygiene (i.e., handwashing), and maintaining isolation of ill residents.	• Behavioural Regulation • Beliefs about Capabilities	• Compatibility
Homes had a hard time keeping up with rapidly evolving protocols and communicating changes to families/caregivers and staff, which led to confusion, fear, anxiety and anger	Directions and protocols were constantly changing, making it difficult for staff to keep track of current protocols and practices. This was especially true for RH who did not always have tailored public health guidance available to them. Many sites had difficulty keeping up with the updates as a result, and experienced challenges with effectively communicating the ongoing changes in IPAC protocol to staff, residents, and caregivers/families.	• Knowledge • Emotion	• Policies & Laws • Available Resources
Resources shortages, including PPE and access to COVID-19 rapid tests	Sites experienced shortage or poor access to PPE for staff members, making it difficult to follow IPAC protocols. This was particularly an issue during the first wave, where there were shortages on all PPE (which they were able to resolve over time), but was also seen later in the pandemic during a shortage of N95 masks following guidance changes. Following recommendations to employ rapid COVID-19 testing during the Omicron wave, sites experienced challenges in acquiring sufficient rapid COVID-19 testing kits in a timely manner, resulting in shortages.	• Environmental context and resources	• Available resources (materials & equipment)
Lack of funding to cover costs related to N95 mask fit testing, staff training for IPAC protocols	While some homes had enough funding or resources in-house to support IPAC (e.g., N95 mask fitting; IPAC protocol training), other homes did not have the necessary resources in house nor sufficient funding to do so.	• Environmental context and resources	• Available resources (funding)
Physical environment of homes not conducive to IPAC implementation	Homes experienced challenges around finding physical space for IPAC supplies, disinfecting large areas, and ensuring physical distancing in an environment that was not built to handle such expectations (e.g., lack of space, small physical space).	• Environmental context and resources	• Structural characteristics (physical infrastructure) • Available resources (space)
PPE fatigue	Staff members and caregivers became tired of wearing PPE, due to discomfort that comes from wearing many layers of PPE consistently throughout their shift; this worsened in warmer weather. This led to PPE burnout and decreased compliance to PPE in many instances.	• Emotion
Family pushback on IPAC protocols	The pandemic led to new levels of distrust and pushback from caregivers/family members to loosen restrictions. Family members called to complain about not being allowed to visit. Some family members requested residents be cared for by vaccinated staff members, creating tensions between staff.	• Beliefs about Consequences • Social professional role/identity • Social influences • Emotion
Fears of returning to normal and loosening IPAC restrictions	Some found adapting to the earlier stages of the pandemic easier because the focus was on constant change. Now some are finding it difficult to loosen IPAC restrictions, for fear of another outbreak. Some expressed a fear of “returning to normal”.	• Beliefs about Consequences • Emotion
Facilitator	Description of Theme
Having a dedicated IPAC manager/nurse/champion	IPAC representatives helped provide advice, answer questions, and supported each site and their staff to ensure IPAC protocols were properly followed.	• Behavioural regulation • Social influences	• Available resources (access to knowledge & information)
Consistent communication with public health units	Some sites had regular communication with their local public health units that provided them with support, education, and information.	• Environmental context and resources	• Partnerships & Connections
External supports from hospitals or public health unit (IPAC guidance, physical or financial resources)	Sites received a range of support/ resources from local public health agencies and external organizations/ hospitals. There was also financial support (e.g., from provincial government) to RH to purchase PPE and cleaning supplies, and hire emergency services to provide onsite support.	• Environmental context and resources	• Available resources (funding) • Structural characteristics (work infrastructure) • Partnerships & Connections
Use of multi-pronged strategies to disseminate IPAC updates to staff	Sites utilized a variety of strategies to disseminate IPAC information and updates to their staff, tailoring formats or leveraging communication strategies they already had in place. Strategies included huddles, town halls, emails, calls, handouts, bulletins, in combination with innovative, interactive, and informal approaches to sharing information.	• Memory, Attention and Decision Processes • Behavioural Regulation • Social Influences	• Communications • Available resources (access to knowledge & information)
Monitoring and audits on IPAC compliance	Sites monitored and conducted audits to ensure staff, caregivers, and visitors comply with IPAC protocols.	• Behavioural regulation • Reinforcement	• External pressure (performance-measurement pressure)
Having leaders who are committed to transparency with staff, families/caregivers	Commitment to communication from leadership, and transparent, ongoing communication among staff, and between staff and caregivers/ families were effective; included open dialogue on challenges around adherence to IPAC guidelines. This fostered trust.	• Environmental context and resources • Social, professional role and identity • Emotion	• Available resources (access to knowledge & information) • Relationship connections • Culture (recipient centeredness)
Homes with physical space conducive to IPAC measure implementation	Having a larger sized home facilitated following IPAC protocols on physical distancing and social isolation. Sites also leveraged other techniques, including restricting movement through cohorting.	• Environmental context and resources • Behavioural regulation	• Structural characteristics (physical infrastructure) • Available resources (space)
Having leaders with experience navigating public health emergencies	Sites with staff who either worked through previous pandemics or earlier COVID-19 waves, were able to help sites navigate the pandemic and associated outbreaks.	• Knowledge • Skills • Social/professional role and identity • Beliefs about consequences	• Available resources (access to knowledge & information)

Table 2

Barriers and facilitators to vaccine uptake, coded to TDF and CFIR
Barrier	Description of Theme	TDF Domain	CFIR Construct
Lack of vaccine availability	Homes experienced challenges with COVID-19 vaccine availability due to interim supply chain issues (i.e., Canada-wide 2nd dose delays) – this delayed vaccination of their staff.	• Environmental context and resources	• Critical incidents • Available resources (materials & equipment)
Mistrust around vaccine safety	There was mistrust from staff, caregivers, and residents around vaccine safety due to the following reasons: - Rapid vaccine approval timelines - Changes in vaccine schedule - Fears about long-term effects and vaccine safety and particularly around fertility, breastfeeding, and pregnancy Members of marginalized communities also experienced mistrust rooted in systemic and historical mistreatment by government and health institutions.	• Beliefs about consequences • Emotion • Knowledge • Environmental context and resources	• Local attitudes • Available resources (access to knowledge & information) • Innovation evidence-base
Belief that the vaccine, particularly boosters, will not improve or impact health outcomes	Some staff did not believe the impact would improve health outcomes; this sentiment was further driven by positive COVID-19 cases and continued COVID-19 restrictions after vaccination.	• Beliefs about consequences • Optimism	• Tension for change
Lack of knowledge, access or ability to get to a vaccine clinic	Staff at sites experienced challenges with accessing vaccine clinics, some of which were due to the following: - Lack of transportation to the vaccine clinic - Inability to find local vaccine clinics - No protected time to travel to a vaccine clinic (staff would rather wait till the vaccines are available at the site) - Inability to book an appointment following the new online vaccine clinic booking system; compounded with long waitlist times	• Environmental context and resources	• Available resources (materials & equipment)
Families’ concerns about vaccine safety impact vaccine uptake among residents who do not have capacity to provide consent	Families who did not want to get vaccinated prevented their loved ones from receiving the vaccines.	• Social influences • Intentions
Beliefs that vaccine mandates are an infringement on labour laws, personal liberties	Sites experienced staff pushing back against vaccine mandates, voicing their concerns that it was against their rights and that they were being forced by their organization to get the vaccine.	• Emotion • Reinforcement	• Policies & Laws • Incentive systems
Facilitator	Description of Theme
Individual-level strategies to promote vaccine confidence	Sites had success with targeting each staff member at an individual-level and engaging leadership to educate staff on the vaccine, promote uptake, and provide them with access to evidence-based information.	• Social, professional role and identity • Knowledge • Beliefs about consequences • Social influences • Reinforcement	• Communications • Available resources (access to knowledge & information) • Relationship connections • Culture (recipient centeredness) • Incentive systems
Organizational level strategies to promote vaccine confidence	Sites also ensured that staff were provided with evidence-based information and education about the vaccine to combat misinformation, including information to explain the rapid approval process. Sites found that informational town halls were an effective strategy for increasing vaccine uptake. Sites utilized opinion leaders and vaccine champions to promote vaccine uptake. Strategies ranged from bringing in staff to speak to historically marginalized populations, having management being the first to get vaccinated, holding vaccine campaigns with champions, and bringing in team members who were negatively impacted by COVID-19 to speak about their experiences.	• Environmental context and resources • Social, professional role and identity	• Compatibility • Culture (recipient centeredness) • Partnerships & connections
Incentives to support vaccine uptake	Some sites provided resources to staff to be vaccinated. This included paying transportation and parking fees for staff as an incentive.	• Reinforcement	• Incentive systems
Improving ease of access to vaccinations for LTCH/RH populations	Sites’ connection to IPAC supports including IPAC hubs facilitated access to vaccine supply and appointments. Sites were also able to overcome logistical barriers to vaccine access by supporting staff with appointment booking or by leveraging mobile clinics/on-site clinics; this likewise included offering vaccines to caregivers while they were onsite visiting residents to facilitate/ encourage uptake.	• Environmental context and resources

Table 3

Barriers and Facilitators to uptake of staff well-being strategies, coded to TDF and CFIR
Theme	Description of Theme	TDF Domain	CFIR Construct
Staff generally reported a lack of access to appropriate mental health and well-being supports in homes	Many homes did not have appropriate mental health supports available. As the pandemic progressed, some supports that were initially put in place were discontinued due to limited resources.	• Environmental context and resources	• Available resources (knowledge & information; materials & equipment) • Structural characteristics (work infrastructure)
Leaders don’t know what to offer	Leaders were not aware of which resources or supports that could be offered to staff to address well-being and mental health challenges related to the COVID-19 pandemic and its effects; some staff did not feel that they had the capacity or skills to offer these supports or that they should be the ones providing the supports	• Knowledge • Cognitive skills • Social/professional role and identity • Environmental context and resources
When available, staff did not access Employee Assistance Programs and other well-being resources; stigma was perceived as a factor.	In situations where well-being resources and supports existed, there remained a lack of uptake. Staff did not have capacity to engage with them, and/or had concerns about stigma and privacy.	• Beliefs about consequences • Social influences
Facilitator	Description of Theme
Home leaders willing and able to implement well-being strategies	To support staff and resident wellness, some sites implemented diverse strategies, which included: - Providing behavioural supports for residents through Behavioural Supports Ontario (BSO) - Limiting number of staff shifts and encouraging use of vacation time - Leveraging support from external organizations to promote staff wellness (e.g., wellness resources from Local Health Integration Networks [LHIN] and regional hospital networks; drop in counselors or psychogeriatric nurses) - Having clinical staff on site with expertise in promoting wellness (e.g., social worker, occupational health) - Offering Employee Assistance Programs - Hosting social activities and staff appreciation events, providing gift certificates - Distributing well-being resources (e.g., bulletins, self-serve resource table)	• Environmental context and resources • Social influences • Beliefs about consequences • Social, professional role and identity	• Culture (recipient centeredness) • Communications • Structural characteristics (work infrastructure) • Partnerships & Connections • Relationship connections

Table 4: Mapping of implementation barriers to the Theoretical Domains Framework and the Consolidated Framework for Implementation Research

Table 5

Wellness Hub Program -Implementation Supports
Wellness Hub Implementation Strategy	Description	Implementation Strategies	Intervention Function / CFIR-ERIC Strategy
Use of a co-created, integrated approach in intervention design, and implementation	Engaged with homes to conduct a needs assessment interview to identify required supports; provided tailored supports to homes as required; continued collection of ongoing formal and informal stakeholder feedback to iteratively tailor and provide support strategies	• Conduct local consensus processes	• Persuasion
Town Halls	Town Halls with experts on vaccine information, to build vaccine confidence, and on mental health and well-being in the LTCH/RH setting	• Educational meetings	• Education • Conduct educational meetings
Implementation coach	1:1 check-ins with an implementation coach to identify evolving barriers and facilitators and suggest corresponding theoretically-linked strategies. Within the research study, some homes had access to on-site days during which study staff collected dried blood spot samples from participants, while facilitating discussions about home needs.	• Use of a learning collaborative • Conduct educational outreach visits	• Enablement • Training • Develop, distribute educational materials
Promotion for LTCH/RH Wellness days	Advertisement and encouragement to use CARE+, Wellness Day resources and a Peer-to-Peer Support Guide to support staff mental health and wellness	• Use mass media	• Persuasion
Infographics and online/printed resources	Infographics, resource booklets tailored to LTCH/RH on IPAC, Vaccine, and Wellness Days. Includes tailored educational materials upon home requests (e.g., IPAC card for lanyard)	• Educational materials	• Education • Develop, distribute educational materials
Online resource repository	Resource repository with dedicated pages to IPAC implementation, vaccine access uptake and confidence, and well-being and mental health supports including original and existing resources	• Educational materials	• Education • Develop, distribute educational materials
Wellness Hub Newsletter	Weekly newsletter providing guidance on IPAC directives and updates (including evolving public health guidance), vaccine access (e.g., how to sign up for vaccine), vaccine confidence (e.g., FAQ about COVID-19 vaccines), advertisements for events and resources, opportunities to participate in a community of practice, lessons learned/spotlight on featured homes.	• Educational materials • Community of practice	• Education
Vaccine Champions Program and e-Learning course	Created a self-directed vaccine champions e-course that provided homes with an opportunity to train staff to become peer champions	• Use of champions • Prepare leadership/staff to be active participants • Use train-the-trainer strategies	• Enablement • Persuasion • Training
Coaching and Modelling	Worked with LTCH/RH leaders to act as IPAC, vaccine and wellness champions in their own settings (e.g., how to plan an onsite wellness day for staff)	• Prepare leadership/staff to be active participants	• Enablement • Persuasion
IPAC Self-assessment tool	Self-directed tool for homes to assess their IPAC implementation that identified gaps and corresponding resources to address gaps	• Preparing leadership/staff to be active participants • Educational materials	• Education • Enablement
$10,000 seed funding and vaccine incentives	Partnered with Healthcare Excellence Canada via their LTC + plus program to facilitate distribution of $10,000 (CAD) for quality improvement/pandemic navigation resources for LTCH/RH. Homes had the authority to select how their funds would be used (e.g., wellness room, staff appreciation incentives, IPAC materials). Partnered with “This is Our Shot” campaign to provide homes with vaccine incentives.	• Public funding and contracting • Alter incentive/allowance structure	• Enablement • Incentivisation • Access new funding
Access to off-site COVID-19 testing	Provided access to at home COVID-19 saliva testing and at home or at work DBS COVID-19 dried blood spot antibody testing (the latter as part of a research project)	• Change service sites	• Environmental restructuring
Monthly community of practice meetings	Encouraged LTCH/RH with successes in a specific domain to share their stories and lessons learned; discussed new challenges and needs; provided featured resources and guest speakers	• Model and simulate change	• Modelling • Educational meetings
Opinion leaders	Via the implementation program and community of practice, we identified opinion leaders and empowered LTCH/RH leaders to identify opinion leaders to support behavior change	• Identify and use local opinion leaders	• Persuasion
Vaccine mandates (external to Wellness Hub program)	Under the Ontario government directive, all LTCH/RH staff were mandated to receive at least 2 doses and 1 booster of the COVID-19 vaccine.	• Mandate change	• Persuasion
Work with educational institutions (external to Wellness Hub program)	Many homes had access to Ontario’s hub-and-spoke model which partnered LTCH with academic and community hospitals to support IPAC implementation and uptake. Where possible, we aimed to facilitate these connections.	• Work with educational institutions	• Training

No competing interests reported.

The Wellness Hub Program: Design of a theoretically-rooted support strategy to leverage facilitators and overcome barriers facing Long-Term Care and Retirement Homes in Ontario during the COVID-19 pandemic

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Trial Registration

Contributions to the Literature

Background

Methods

Results

Barriers and Facilitators Mapping to Theoretical Domains

Identification of Corresponding Strategies

Development of the Wellness Hub Support Strategy

Discussion

Conclusion

Abbreviations

Declarations

Competing interests:

Funding:

Author Contribution

Acknowledgement

Availability of data and materials:

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1