Using the Implementation Research Logic Model to Examine High-Intensity Resistance Rehabilitation Implementation in Skilled Nursing Facilities: A Mixed Methods Multi-Site Case Study

doi:10.21203/rs.3.rs-4844607/v1

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Research Article

Using the Implementation Research Logic Model to Examine High-Intensity Resistance Rehabilitation Implementation in Skilled Nursing Facilities: A Mixed Methods Multi-Site Case Study

https://doi.org/10.21203/rs.3.rs-4844607/v1

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Background

Implementing evidence-based rehabilitation in skilled nursing facilities (SNFs) is essential for enhancing physical function outcomes and mitigating risk of adverse events. Best implementation approaches in this complex setting are unknown. This study uses the Implementation Research Logic Model (IRLM) to examine the implementation of high-intensity resistance rehabilitation (HIR) in SNFs, aiming to elucidate contextual factors and processes that could enhance future HIR implementation endeavors.

Methods

We conducted a mixed-methods multi-site case study (n = 8 sites) to examine implementation. A standardized implementation strategy was employed, allowing sites to tailor their approaches. Use of HIR was measured using the Provider Report of Sustainment Scale (PRESS). Contextual factors were identified using the Practical Robust Implementation and Sustainability Model (PRISM) through study-specific questionnaires and validated measures (Inner Setting Scale, Provider Perspective of Team Effectiveness, Evidence Based Practice Attitudes Scale, Perceived Characteristics of Intervention Scale, Self-Defined Burnout Measure, and Utrecht Engagement Scale), and analyzed descriptively. Interviews and focus groups with leadership and clinicians revealed contextual factors and processes influencing implementation. Heat maps visualized site trends, while an Implementation Research Logic Model (IRLM) proposed provisional implementation processes.

Results

PRESS scores ranged from 3.75 (0.17) to 2.33 (0.67) indicating all sites implemented HIR to at least a “moderate extent”. Higher-implementing sites demonstrated full-team ability to accommodate HIR to diverse patients. Differentiating factors between higher and lower implementing sites included clinician perspectives, site infrastructure, and satisfaction with leadership. Higher-implementing sites employed a higher volume of site-initiated implementation strategies, notably having a champion and consumer engagement. Processes that appeared to contribute to higher implementation extent included: 1) overcoming inertia of current practice through salience, 2) overcoming clinician concerns of patient compatibility through affirmative experiences, 3) addressing clinician perspective of complexity with session planning, and 4) optimizing patient rehabilitation mindset through encouraging environments.

Conclusion

Improving physical function in older adults necessitates adoption of evidence-based rehabilitation like HIR. Implementation strategies that target infrastructure, including leadership support and communication channels, inertia of current practice, and clinician perspectives of HIR complexity and patient compatibility may facilitate implementation. Identifying a champion and providing guidance for effective patient engagement appear to be key.

geriatrics

skilled nursing facilities

implementation

exercise therapy

rehabilitation

Knowledge on implementing evidence-based programs shown to improve physical function and reduce the risk of adverse events among frail, older adults within the complex and underrepresented context of skilled nursing facility rehabilitation is limited.
This study identifies the importance of considering strategies that address clinician perspectives, site infrastructure (including leadership support and communication channels), existing practice inertia, and patients’ rehabilitation mindset. These strategies are suggested to promote environmental adaptations and cues, clinician creativity and self-efficacy, continuity of care, and supportive patient environments.
Findings can inform future efforts aimed at implementing evidence-based rehabilitation practices in skilled nursing facilities.

The objective of rehabilitation in Skilled Nursing Facilities (SNFs) is to improve physical function for patients who experience hospital-associated functional deficits. Over 60% of patients discharged from SNFs are at functional levels that put them at heightened risk for adverse events (1–4). Fortunately, physical function is a modifiable risk factor (5, 6), but implementation of rehabilitation interventions that more effectively improve physical function are necessary.

One such rehabilitation intervention is progressive, high-intensity resistance rehabilitation (HIR), which directly targets muscle weakness to improve physical function among patients with medical complexities (7). HIR involves physiologically overloading skeletal muscle through low-repetition, high-resistance activities. It is safe and effective in improving physical function among older adults with medical complexities, specifically in SNFs (8). However, its implementation across a limited number of SNFs (n = 3) has shown mixed implementation success (8, 9) and understanding the key processes and factors influencing its implementation remains limited (9).

Skilled nursing facilities are underrepresented in rehabilitation research and pose implementation challenges given various levels of complexity, including care models where patients are treated by multiple rehabilitation professionals within the same discipline, high staff turnover rates (9–11). Therefore, examining HIR implementation at the facility or site level is necessary, requiring consideration of multi-level factors, including team dynamics and the physical and sociocultural environmental context. Additionally, it is important to identify if and how sites modify a standard implementation approach through introduction of their own, site-initiated implementation strategy and assess the impact of these introductions (12). To develop more generalized recommendations for HIR implementation, it is important to examine HIR implementation across multiple sites due to the common variation in outcomes observed in multisite implementation efforts (13).

Achieving rigorous, reproducible, and actionable examination requires the integration of multiple theories, models, or frameworks through a logic model (14–25). The Implementation Research Logic Model (IRLM) serves as a tool by connecting multi-level contextual factors, implementation strategies, and outcomes (24). This linkage allows identification of potential influential processes through which implementation strategies affect desired outcomes (21). Identifying and describing processes is a key priority in implementation science. It can improve the design, tailoring, and adaptation of implementation strategies; facilitate replication and scaling; and improve overall impact (21, 26).

Accordingly, this study uses a multi-site case study design to develop an IRLM and examine HIR implementation by: 1) determining the extent of implementation per site, 2) systematically identifying factors influencing HIR implementation, 3) systematically identifying site-initiated implementation strategies, and 4) linking factors and strategies using the Implementation Research Logic Model to propose provisional processes for HIR implementation in SNFs. Upon completion, the drafted IRLM will guide planning of additional HIR implementation efforts.

This paper follows the reporting standards: Standards for Reporting Implementation Studies (StaRI)(27), Mixed Methods Reporting in Rehabilitation and Health Sciences (MMR-RHS)(28), Standards for Reporting Qualitative Research (SRQR)(29) (Additional File 1).

As part of a collection of efforts to enhance SNF rehabilitation through HIR implementation, this study employed a mixed-methods multi-site case study following methods outlined by Yin (30) and Fetters (31) at eight geographically diverse Veteran’s Health Administration (VHA) SNFs in the United States participating in a quality improvement initiative to implement HIR. A waiver of documentation of informed consent was obtained from both the VA Research Administration Office and the University of Colorado Anschutz Medical Center Institutional Review Board (IRB number 21-4637).

Sites were recruited through VHA email lists targeting medical and rehabilitation directors. Sites were included once they confirmed consistent admission of short-term stay patients and committed to facilitating participation of full-time and part-time rehabilitation clinicians (i.e., physical therapists, physical therapy assistants, occupational therapists, and occupational therapy assistants) in an 18-week HIR implementation program. This program included a standardized, research-led multicomponent implementation strategy, participation in focus groups, questionnaire completion. Site demographics are presented in Table 1.

Table 1

Site Demographics
		Site A	Site B	Site C	Site D	Site E	Site F	Site G	Site H
Rehabilitation Staff Size
		5	4	2	4	8	12	4	6
Discipline
	PT	2 (40%)	2 (50%)	1 (50%)	1 (25%)	2 (25%)	3 (25%)	1 (25%)	2 (33%)
	PTA	1 (20%)	1 (25%)	0	1 (25%)	1 (13%)	1 (8%)	2 (50%)	1 (17%)
	OT	2 (40%)	1 (25%)	1 (50%)	1 (25%)	3 (38%)	3 (25%)	1 (25%)	2(33%)
	OTA	0	0	0	1(25%)	1 (13%)	1 (8%)	0	1 (17%)
	KT	0	0	0	0	0	4 (33%)	0	0
	Other	0	0	0	0	1 (13%)	0	0	0
Specialty Certification Indicated
		0 (0%)	2 (50%)	1 (50%)	0 (0%)	2 (25%)	7 (58.33%)	1 (25%)	0 (0%)
Years in practice
Mean (SD) Range		15.60 (12.19) 5–36	22.50 (7.32) 15–31	31.50 (3.54) 29–34	11.00 (11.63) 1–27	17.25 (11.13) 5–30	15.58 (9.14) 3–30	22.50 (9.57) 10–30	12.42 (7.05) 5–24
Years in current role
Mean (SD) Range		7.50 (5.57) 2–15	4.50 (2.65) 1–7	18.50 (9.19) 12–25	9.50 (9.75) 1–23	7.75 (9.31) 1–29	9.29 (4.75) 3–18	17.5 (10.34) 6–30	5.88 (9.03) 0.25-24
Gender
	Male	1 (20%)	1 (25%)	0	2 (50%)	2 (25%)	3 (25%)	1 (25%)	1 (17%)
	Female	4 (80%)	3 (75%)	2 (100%)	2 (50%)	6 (75%)	9 (75%)	3 (75%)	5 (83%)
Race
	Am Ind	0	0	0	0	0	0	0	0
	Asian	1 (20%)	1 (25%)	0	0	0	0	0	5 (83%)
	Black	0	0	1 (50%)	0	0	2 (17%)	0	0
	White	4 (80%)	2 (50%)	1 (50%)	4 (100%)	8 (100%)	10 (83%)	3 (75%)	0
	Multiracial	0	0	0	0	0	0	0	1 (17%)
	Other or unknown	0	1 (25%)	0	0	0	0	1 (25%)	0
Ethnicity
	Hispanic	0	3 (75%)	0	2	1 (13%)	1 (8%)	0	0
	Non-Hispanic	5 (100%)	1 (25%)	2 (100%)	2 (100%)	7 (87%)	10 (83%)	3 (75%)	6 (100%)
	Unknown	0	0	0	0	0	1 (8%)	1 (25%)	0
All sites are part of the Veterans Health Administration. PT = physical therapist; PTA = physical therapy assistant; OT = occupational therapist; OTA = occupational therapy assistant; KT = kinesiotherapist. Am Ind = American Indian

Prior to the kickoff meetings launching the 18-week program, the research team did not directly contact clinicians. Instead, medical and rehabilitation directors were asked to distribute a one-page program overview and description of HIR to clinicians. Figure 1 illustrates the timing and components of the standardized, research-led multicomponent implementation strategy while additional files 2 and 3 further detail HIR and the standardized implementation strategy following established reporting procedures.

[insert Table 1]

[insert Fig. 1]

Implementation Research Logic Model

Our Implementation Research Logic Model (IRLM) included the Practical Robust Implementation and Sustainability Model (PRISM), its Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) outcomes framework, and the Expert Recommendation for Implementing Change (ERIC) (Fig. 2a and Table 2). PRISM offers a comprehensive model of contextual factors hypothesized to influence implementation outcomes, considering characteristics and perspectives of organizations, staff, and beneficiaries of evidence-based interventions. PRISM guided the identification of factors influencing HIR implementation (20, 32–35). ERIC helped organize and describe site-initiated implementation strategies employed in addition to the standard research-led strategy (17, 36, 37).

Table 2

Study Frameworks, Constructs, and Associated Data Sources
Framework	Use in study	Construct or Domain	Quantitative Questionnaires	Questionnaire Scoring
PRISM	PRISM guided identification and description of factors influencing site implementation. Focus group and interview guides and a deductive coding structure were developed according to PRISM constructs. Quantitative questionnaires were selected to represent PRISM constructs.	Organizational Characteristics
		Culture	Inner Setting Scale (39) culture, culture stress, culture effort, learning climate)	1–5*
		Leadership	Inner Setting Scale (39) (leadership engagement), 1-item study-derived questionnaire assessing satisfaction with leadership	1–5* 1–3*
		Moral	Self-Defined Burnout Measure (40) Utrecht Engagement Scale (42) 4-item study-derived work satisfaction questionnaire	1–5† 0–6* 1–5*
		Team Effectiveness & Communication	Provider Perspective of Team Effectiveness Questionnaire (44) 3-item study-derived questionnaire assessing communication satisfaction	1–6* 1–3*
		Clinician Characteristics
		Knowledge	Post-training assessment of didactic knowledge	0-100*
		Self-Efficacy	Post-training assessment of confidence in ability to integrate high-intensity resistance rehabilitation into clinical care	1–5*
		Evidence Based Practice Attitude	Evidence Based Practice Attitudes Scale (EBPAS) (45)	0–4*
		Implementation and Sustainability Infrastructure
		Change Capacity	5-item study-derived questionnaire to identify capacity specific to implementing high-intensity resistance rehabilitation including resources, time, leadership support, communication channels, perceived need	1–5*
		Implementation Climate	Implementation Climate (Inner Setting Scale) (39)	1–5*
		Clinician Perspectives of High-Intensity Resistance Rehabilitation
		Perspective of Intervention	Perceived Characteristics of Intervention Scale (PCIS) (46) • Positive Sub Score • Risk Sub score	1–5* 1–5†
RE-AIM	RE-AIM represents salient implementation outcomes. For this study, implementation was evaluated through a quantitative measure triangulated with qualitative data.	Implementation	Provider Report of Sustainment Scale (PRESS)	0–4*
ERIC	ERIC assisted in description of a priori implementation strategies along with identification and description of any actions taken by sites to encourage implementation. Focus group and interview guides and a deductive coding structure were developed according to ERIC.			NA
PRISM = Practical Robust Implementation and Sustainability Model; ERIC = Expert Recommendations for Implementing Change; RE-AIM = Reach, Effectiveness, Adoption, Implementation, Maintenance.
*indicates higher scores as more favorable
†indicates higher scores as least favorable.

[insert Table 2]

[insert Fig. 2]

Data collection

Qualitative and quantitative data assessing elements of the IRLM included questionnaires, semi-structured leadership interviews, and clinician focus groups (38) (Table 2 and Fig. 1). We used Research Electronic Data Capture (REDCap), (39, 40) hosted at University of Colorado, to collect and manage questionnaire data. A case study database developed in Microsoft Excel managed the multiple data sources (30, 38, 41).

Quantitative questionnaires

At the time of this work, no established questionnaires existed for quantitatively assessing or describing PRISM constructs. Consequently, questionnaires that best capture PRISM constructs and RE-AIM outcomes were identified through a literature search (Table 2). Additional file 4 details each questionnaire.

Questionnaires of site implementation

Due to COVID-related restrictions and limited access to electronic medical records, remote measurement of site implementation was conducted through a clinician questionnaire, the Provider Report of Sustainment Scale (PRESS) which consists of three questions on a 0 to 4 scale with higher scores indicating greater extent of implementation (42). The PRESS was selected as a practical measure aligned with RE-AIMs definition of implementation, focusing on the consistency of intervention delivery (43). While the scale’s title mentions “sustainment”, its questions assess the extent to which staff integrates an evidence-based practice into routine practice, reflecting implementation consistency (42).

Questionnaires of contextual factors

Organizational Characteristics, including culture, leadership, morale, and team effectiveness, were assessed. The Inner Setting Scale (44), a valid and reliable measure of organizational culture, climate, and leadership (44), was employed to gauge organizational culture, climate, and leadership. Leadership communication satisfaction was evaluated through a single item, Likert question. Morale was measured via three surveys: the Self-Defined Burnout Measure (45, 46) for clinician burnout, the Utrecht Engagement Scale (UWES-3) (47) for work engagement, and a study-specific 4-item questionnaire for overall work satisfaction. Given that SNF rehabilitation relies on interdisciplinary team efforts and cohesiveness (48), team effectiveness was assessed using adapted items from the Provider Perspective of Team Effectiveness Questionnaire (49) (Provider-PTE), focusing on coordination, cohesion, problem-solving, and focus along with queries regarding communication patterns and satisfaction.

Clinician Characteristics of interest included knowledge regarding HIR, self-efficacy in implementing HIR, and general evidence-based practice attitudes. Didactic knowledge and self-efficacy were measured using study-derived tools. The Evidence Based Practice Attitude Scale (50) measured clinician attitudes towards general evidence-based practice.

Implementation and Sustainability Infrastructure was assessed using the implementation climate subscale of the Inner Setting Scale (44) and a 5-item questionnaire developed to comprehensively measure change capacity including existing resources, leadership support, and communication channels required for HIR implementation.

Clinician Perspective of HIR was measured using the Perceived Characteristics of Intervention Scale (51). This scale is largely based on Rogers Theory of Innovation with constructs added by Greenhalgh et al.,(52) and results can be presented across two scores: positive perspectives and perspective of risk (53).

Qualitative data collection

A post-positivist theoretical framework (54) guided a heavily deductive approach (55–57). Rigor was ensured using methods by Morse, et al. including responsiveness, verification, methodological coherence, theoretical and adequate sampling, and an active analytic stance (58). Semi-structured interview and focus group guides were developed based on study aims and frameworks, and iteratively refined after team piloting. Following purposive sampling, participants included all leaders (i.e., Medical Directors, Directors of Rehabilitation) and clinicians involved in the quality improvement initiative. Two leadership interviews and four clinician focus groups occurred per site at various stages of the initiative. (Fig. 1). Interviews and focus groups lasting 30–60 minutes were conducted on Microsoft Teams during clinic hours by two research personnel also serving as external implementation facilitators. Post-data collection, a debrief form was completed by the research personnel.

Data analysis

Steps of data analysis are outlined in Fig. 3. To determine implementation extent and describe potential influencing factors, descriptive statistics [mean (SD), median (IQR), or frequency (percentage) where appropriate] of PRESS and PRISM constructs per site were calculated using SAS OnDemand for Academics (SAS Institute Inc. 2023). Also to determine implementation extent and identify PRISM constructs along with site-initiated strategies and implementation processes, interviews and focus groups were recorded, transcribed verbatim, checked for accuracy, uploaded to Atlas.ti Windows (Version 23.2.2) (59) qualitative management software, and analyzed using a hybrid deductive and inductive coding, thematic matrix analysis, and narrative case summaries (60, 61). A team of four researchers, two of which facilitated data collection, doubled coded all transcripts. Consensus meetings were held with the study team for discussing the valence and salience of identified processes and contextual factors and within- and across-case analysis including narrative case summaries and provisional pathways (30). Necessary steps were taken to minimize bias and subjectivity within the analysis team including triangulation across four researchers and reflexivity.

[insert Fig. 3]

Mixed method analysis

Mixing data types occurred through various approaches. To determine extent of HIR implementation, data types were merged via joint display and evaluated for congruence and expansion (31, 62, 63).

Known for their effectiveness in visualizing patterns in small-sampled studies, we generated three heat maps to identify trends in contextual factors, site-initiated strategies, and processes: 1) quantitative heat map, 2) qualitative heat map, and 3) site-initiated strategy heat map(64). Due to the absence of established cut-off scores for questionnaires, an exploratory method was used. Data were organized into a matrix with rows representing individual sites and columns depicting PRISM constructs or site-initiated strategies. Using Microsoft Excel programing, a 5-color gradient was assigned to questionnaire scores for the quantitative heat map, and to valence of themes for the qualitative heat map. A 2-color scale was applied to the site-initiated strategy heat map indicating presence or absence of the strategy. To examine potential contextual factors influencing implementation extent, sites (rows) were ordered and classified by quartiles based on their implementation extent (PRESS scores): the upper quartile indicated high extent of implementation, the middle quartile denoted moderate extent, and the lower quartile suggested comparatively lower extent of implementation (65) Finally, we searched for common patterns across the heat maps.

Proposal of provisional implementation processes occurred in three steps. First, an IRLM was constructed for each site, revealing site-specific insights. Second, common elements across sites were extracted to formulate a comprehensive IRLM for HIR implementation in SNFs. Third, processes identified in the comprehensive IRLM were named and described, guided by existing literature (66).

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.

Site-level implementation

Concordance was observed in merging data strands describing implementation (Table 3). PRESS scores ranged from 3.75 (0.17) to 2.33 (0.67) on a 4-point scale, with all sites implementing HIR to at least a “moderate extent”.

Table 3

Mixed Methods Findings Representing Site-Level Implementation
	Site D	Site C	Site E	Site F	Site G	Site B	Site H	Site A
PRESS Score*	3.75 (0.17)	3.33 (0.47)	2.88 (0.17)	2.63 (0.90)	2.58 (0.50)	2.58 (0.96)	2.44 (0.50)	2.33 (0.67)
Quartile	Upper		Middle				Lower
Qualitative	Thick, rich examples provided across clinical roles, rehabilitation interventions, and patient populations	Thick, rich examples provided across clinical roles, rehabilitation interventions, and patient populations	Thick, rich examples provided by PT/OT; moderate volume and specificity of examples provided by PTA/OTA	Limited volume and specificity of examples across team	Limited examples provided by assistant team (PTA, OTA)	Limited examples provided by OT team	Minimal examples provided across team	Minimal examples provided across team
Meta-inferences	Concordance identified across data strands for implementation. Higher-implementing sites demonstrated collective team implementation while lower-implementing sites lacked collective team implementation. Sites in the middle quartile appeared to have a clinician group (either occupational therapy or assistants) that implemented to a limited extent.
*Mean (SD). Sites presented in order of highest to lowest score on a 4-point scale

[Insert Table 3]

Qualitatively, all sites reported examples of implementing HIR, but variations were noted in the depth, specificity, variety, and volume of these examples. This included variation in adapting HIR across different rehabilitation interventions to accommodate diverse patient populations and in the representation of team members offering examples. Higher-implementing sites (upper quartile PRESS score) showcased greater depth, specificity, variety, and volume of implementation examples involving the entire team, indicating more comprehensive implementation. Conversely, lower-implementing sites (lower quartile PRESS score) presented implementation examples with limited depth, specificity, variety, and volume, along with inconsistencies across the team. For instance, one lower-implementing site provided specific implementation examples from supervising therapists but fewer from therapy assistants, while another site had occupational therapy team members who did not contribute examples.

Contextual Factors

Figures 4a-b and additional file 5 presents contextual factors findings. Clinician perspectives, site infrastructure, and general satisfaction with leadership engagement were identified as key contextual factors shared across data types delineating the contrast between higher-implementing and lower-implementing sites. Quantitatively measured contextual differences between higher and lower implementing sites can mostly be observed in the organizational characteristics (leadership engagement), infrastructure (resources, time, leadership support, necessary communication channels, tension for change, implementation climate), and clinician perspective domains.

Qualitative data provided deeper insights into the nuances of clinician perspectives highlighting perspectives of HIR complexity and patient compatibility as delineating constructs. These data also expanded our understanding of delineating factors that were not measured quantitatively, specifically shedding light on the impact patient characteristics (rehabilitation mindset). Across most sites, strong facilitators of HIR implementation included: 1) the environment of the Veterans Health Administration encompassing clinician autonomy, clinician access to medical records, models of care, and Veterans’ experience with physical exertion, 2) a collaborative and patient-centered interdisciplinary team culture, 3) clinician openness to change, 4) supportive infrastructure for sharing best practices and critical patient details, and 5) clinician recognition of HIR adaptability and value through its ability to improve functional outcomes more quickly than prior rehabilitation approaches. Common barriers comprised of external factors including COVID-related challenges and SNF stigma, inertia of existing practice, patients with low cognitive status, and resource constraints (e.g., limited resistance equipment and space).

[insert Fig. 4]

Site-initiated implementation strategies and their impact

Figure 4c and additional file 6 present site-initiated implementation strategies and impact. All sites attempted to overcome barriers by initiating their own implementation strategies alongside the standard research-led strategy. Site-initiated strategies were categorized into ERIC thematic clusters: 1) evaluative and iterative strategies, 2) infrastructure change, 3) consumer engagement, 4) stakeholder interrelationships, 5) interactive assistance for clinicians, and 6) adaptation and tailoring. Among these, stakeholder interrelationships, notably shifting rehabilitation team communication to include HIR discussions, emerged as the most utilized strategy. This was followed by adapting HIR to fit patient contexts and engaging consumers (patients). Clinicians and leaders credited the impact of these strategies to the following: 1) enhancing clinician positive perspective, 2) creating a positive patient environment, 3) providing early affirmative experiences, 4) decreasing cognitive effort through session planning and execution, 5) enhancing adaptation capacity and confidence, 6) optimizing care continuity, 7) and HIR salience. Higher implementing sites reported a higher use of site-initiating strategies, in addition to the research-led strategies. Strategies that differentiated higher from lower implementing sites included consumer engagement, adaptation, presence of an informal champion, and early team engagement.

Provisional implementation processes

Using shared contextual factors and strategies to construct a single IRLM representing implementation across all sites allowed development of provisional processes contributing to implementation: 1) overcoming inertia of current practice through salience, 2) overcoming clinician concerns of patient compatibility through affirmative experience, 3) addressing clinicians perspective of complexity with session planning and 4) optimizing patient rehabilitation mindset through encouraging environments (Fig. 2b).

1. Overcoming inertia of current practice through salience

When clinicians experienced the barrier of inertia of current practice, sites initiated strategies that improved implementation by making HIR more salient. This included frequent team discussion of HIR, hanging of job aids (a resourced offered by the research team as a quick reference guide to patient screening and dosing principles), changes in documentation, and/or emergence of an informal champion.

The job aids…where to position them in the gym or giving them out individually to each of us so that we always got a visual prompt for, okay, are you checking this? Are you trying these things? Are you progressing through this? Not only are we accountable to each other but throughout the day we’ll visually have a reminder of continuing to incorporate that and push our patients as well. (PT 7)

…even small things like making it part of our consult template. “Is this patient potentially appropriate for high intensity rehab, methodology” to just continue to keep that in their mindset that, “Hey, I’ve got to keep remembering that this is how we do things.” after a period of time, I would hope that this is what comes first when you think about taking care of a patient. (Leader 6)

2. Overcoming clinician perceived lack of patient compatibility through affirmative experiences

Sites overcame clinician perspective of limited compatibility between HIR and patients by promoting team discussion, co-treating, or the emergence informal champions. These actions improved implementation through support and mentorship, boosting clinicians’ confidence and ability to adapt HIR to diverse patient contexts. Experiencing this support, along with observing their enhanced HIR delivery skills and positive patient responses, created affirmative experiences for clinicians.

I almost saw a little pullback from her when she seemed to think this is mostly a PT thing. I talked to her, and was like this is universally applicable. You could break it down to even hand squeezes. The level of anything that needs strengthening, we just need to do on different parameters to really get the optimal strength gain. I think she was seeing it more and more as it was going along and I see them utilizing it more now. (Leader 4)

3. Addressing clinician perspective of complexity with session planning

The barrier of perceived HIR complexity was addressed by visually displaying job aids and refining specificity of documentation, verbal patient handoffs, and team discussion. These strategies decreased the cognitive effort required to implement HIR through more efficient care continuity, session planning, and identification of intervention ideas.

Here we have more discussion as a team…we have a great team as far as the creative really goes, we can come up with some crazy ideas. (PT 1)

4. Optimizing patient rehabilitation mindset through encouraging environments

Clinicians targeted patient rehabilitation mindset and engagement with HIR by using strategies that created an environment of trust, peer normalization, and enthusiasm. These strategies included co-treating, group or concurrent sessions, and adapted patient communication.

I was explaining it to them as we went. “I really want to work with you at a higher challenging level so that we can see results a little bit quicker. If I just keep having you push through, doing three sets of 10 and you're not seeing any benefit in it, then, it's not benefiting you." they really did seem to buy in. It seemed like there was a little spark that came to life in them as they were finding those levels of challenge. So I think they really did enjoy it at the end. (PTA 2)

…that’s very helpful to provide that education…. to remember to instead of just you monitoring the vitals to bring them [patients] into it. (OT 5)

This study sought to enhance understanding of HIR implementation in SNFs by employing mixed method multi-site case study methodology. Through this approach, we examined HIR implementation and systematically identified influential contextual factors and site-initiated implementation strategies. By using an IRLM, we propose four provisional pathways of HIR implementation in SNFs to inform future implementation efforts.

Previous research underscores the significance of organizational systems, team dynamics, patient and therapist self-efficacy, and perspectives of intervention effectiveness in driving rehabilitation practice change in SNFs (9) This study adds specificity to these influencing factors including perspectives of HIR complexity and patient compatibility, patient factors including clinician-reported patient agreement, inertia of existing practice, and infrastructure while also offering suggestions or identifying processes for how to better target these factors.

Many clinical teams were hesitant to use HIR because they perceived it to have low compatibility with patient needs and abilities and believed that its high delivery complexity would require more time for implementation. Based on the research team’s prior HIR implementation experience, these perspectives were anticipated. Efforts to address this included training with worked examples, efficiency steps, and patient testimonials, but these measures were insufficient to overcome this barrier. Results indicate that clinicians need direct mentoring tailored to their unique patients to build confidence in efficiently adapting HIR. They also require early implementation support through observational learning, social models, and direct experience of successful outcomes for themselves and their patients. This will enhance positive outcome expectations, which is important for behavior change (67–69). This can be facilitated by a Champion, co-treating, team idea sharing, or setting both short- and long-term realistic implementation goals (70). Also to address complexity and perceived increased time requirement for implementation, sites enhanced their specificity of documentation and patient handoffs. Future HIR implementation efforts should provide better support for adapting HIR to diverse patient presentations through worked examples, offer more mentored adaptation practice, empower Champions with mentoring skills, and improve patient handoff processes.

Implementation models emphasize patient characteristics, with nearly half of rehabilitation implementation studies citing patient needs as influential (71). Clinicians identified patient attributes, such as cognition, willingness to engage in rehabilitation, mindset, affect, and self-efficacy as notable barriers to HIR implementation. Therapists indicated that patient’s previous rehabilitation experience and anticipated discharge destination influenced patient mindset, affect, and willingness to engage. Interestingly, clinicians from higher-implementing sites viewed patient characteristics as less of a barrier, raising questions about differences in patient case mixes or their ability to overcome patient-related challenges. Some sites worked to overcome this patient-related challenge by adapting communication and shifting their care model to include more co-treats (more than one clinician simultaneously providing rehabilitation to a patient) and concurrent or group therapies (one clinician providing rehabilitation to more than one patient simultaneously), aiming to foster patient trust, peer encouragement and enthusiasm, and establish HIR as a social norm. Although these approaches may not be feasible everywhere, identifying their impact helps guide the selection of other strategies to enhance patient engagement by building trust and establishing social norms. To better understand patient characteristics as an influencing factor and determine necessary implementation strategies, patient perspectives on HIR is needed.

The inertia of existing practices significantly influences implementation of other practices. Our results indicate that multiple approaches can be employed to enhance HIR salience to overcome this momentum and thus improve implementation of HIR. These approaches encompass engaging in regular team discussion or “huddles”, the presence of a Champion, or changing site infrastructure including documentation prompts or the visual display of job aids. Another consideration may include incentives and recognition including the integration of HIR applications into annual performance reviews (72, 73). Furthermore, to bolster salience and implementation of HIR, a behavioral economics perspective may prove beneficial. This involves a deeper understanding of clinician decision-making processes and heuristics, along with using strategies like nudging or adjusting choice architecture for clinicians. For instance, structuring the physical environment to ensure that necessary equipment is prominently displayed and easily accessible can facilitate HIR implementation.(74)

Infrastructure plays an important role in implementation efforts (34). Key subconstructs for HIR implementation included 1) resources (physical and time), 2) leadership support and acknowledgement, 3) channels to share best practice and critical patient details, and 4) shared expectation, prioritization, and tension for change. Higher-implementing sites employed more site-initiated implementation strategies, suggesting their infrastructure may be better suited for strategy deployment. To implement HIR to a high extent, efforts should focus on fostering this constructive infrastructure. Specifically, higher-implementing sites had leaders who balanced oversight and autonomy, remained aware of program progress, provided individualized acknowledgment and mentorship, and were sensitive to clinician needs and preferences. Sites lacking such leadership indicated its need, while leaders requested guidance on how to support their clinical teams. These findings are supported empirically (75–78) and by the many implementation frameworks positing that leadership serves a critical role in implementation across diverse fields (14, 32, 79). Guided by our findings and those from a recent review on leadership in implementation, (78) future efforts will develop and pilot strategies targeting leadership to optimize implementation.

The interconnectedness of PRISM constructs adds complexity to interpretation of our Findings, but it also underscores the need for critical next steps. This includes investigating key factors to determine if they are influenced by deeper, underlying issues. If so, these issues may need to be addressed due to their widespread impact. For example, initial hesitancy from all clinicians was fueled by low perspectives of HIR compatibility with typical SNF patient populations. This perspective may be fueled by an underlying level of stigma including ageism. Though no empirical work regarding stigma in SNF could be found, literature demonstrates how ageism can negatively impact quality of care provided (80) and is harmful to older adult health and well-being (81). Specifically in rehabilitation, ageism leads to under-dosing of exercise interventions, reduced attention to patients' concerns, a lack of empathy, and a decreased likelihood of promoting physical activity (82–84). This contrasts with the American Physical Therapy Association’s guidelines for the Choosing Wisely campaign, which include the recommendation, "Do not prescribe underdosed strength training programs for older adults” (85).

Limitations

This work used a novel mixed-methods approach but has limitations. First, team implementation was measured via self-report survey and not actual fidelity, a core element of implementation. Though the survey was validated, observation and chart-audit likely more accurately represent implementation. Observation was not feasible during the study period due to the COVID-19 health crisis. Chart-audit does not accurately capture implementation fidelity (e.g., target HIR dosing delivered) given documentation insufficiency. Future work will include both custom EMR fields with chart audits and observation to measure adoption and implementation. Second, due to difficulty scheduling, a full clinical team was not present at all focus groups; thus, findings may not represent the experience and perspectives of the entire clinical team. Third, there are no validated surveys to assess PRISM constructs. We used PRISM to select survey tools developed from other theories and frameworks, and to guide development of custom surveys. This may result in slight misrepresentation of PRISM constructs. This is, however, a known limitation in implementation research across many determinant frameworks, and we addressed this issue by using PRISM literature to guide qualitative data collection and a hybrid inductive/deductive analytical approach to allow for breadth of contextual factor identification. Finally, the generalizability of our findings beyond the VHA is somewhat limited. Given the sites’ perceived contextual differences between the VHA and the private sector influence implementation, one must take caution when applying these findings to sites external to the VHA.

Despite limitations, to our knowledge this study is the first in SNF implementation to rigorously report strategies and their connection to contextual factors, identifying provisional processes for effective implementation. These results help understand not only what strategies are needed for HIR implementation in SNFs, but why they are necessary, what they target, and how they influence implementation extent. Collectively, these findings will aid future strategic decision-making and resource allocation.

In conclusion, this multi-site case study identified contextual factors and site-initiated implementation strategies across eight sites that implemented HIR. This facilitated the creation of provisional processes to consider when implementing HIR in other contexts and highlights shortcomings of our current strategy. Results guide refinement of a current HIR implementation strategy to better target salient influential factors and implementation processes. To improve HIR implementation, future work must 1) target infrastructure, including leadership support and communication channels; inertia of current practice; and clinician experience of patient agreeability to HIR as well as perspectives of HIR complexity and patient compatibility and 2) seek to understand patient perspectives and experiences. Implementation strategies to consider include revision of current clinician education to better address clinician perspectives, formalization of team discussion and care continuity, patient engagement, a leadership toolkit, and identification and training of champions. The intent is for these strategies to promote HIR salience, clinician adaptation capacity, affirmative experiences and positive outcome expectation, efficiency with session planning, and a positive patient environment of trust and social normalization of HIR.

Veterans Health Administration (VHA); Skilled Nursing Facilities (SNFs); high-intensity resistance rehabilitation (HIR); Implementation Research Logic Model (IRLM); Practical Robust Implementation and Sustainability Model (PRISM); Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM); Expert Recommendation for Implementing Change (ERIC); physical therapist (PT); physical therapy assistant (PTA); occupational therapist (OT)

Ethics approval and consent to participate: The Colorado Multiple Institutional Review Board (IRB number 21-4637) granted a waiver for written informed consent, as this was part of a larger quality improvement initiative. All clinicians were informed that participation in questionnaires and focus groups was voluntary and provided verbal consent.
Consent for publication: Not applicable
Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Competing interests: The authors declare that they have no competing interests
Funding: The following support has been provided during the completion of this work. LHK received funding from the Promotion of Doctoral Studies (PODS) I Scholarship provided by the Foundation for Physical Therapy Research and from the VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC) Advanced Geriatrics Fellowship. MEP received funding from the VA Eastern Colorado Center of Innovation’s Advanced Fellowship. JES received funding from the National Institutes of Health and United States Department of Veterans Affairs (VHA Office of Rural Health Veterans Rural Health Resource Center – Gainesville). Some of the authors are federal employees of the U.S. Government. This work was prepared as part of their official duties. Title 17 U.S.C. 105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17 U.S.C. 101 defines a U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties. The views expressed herein are those of the authors and do not necessarily reflect the position or policy of the Department of the Navy, Department of Defense, Department of Veterans Affairs, or the United States Government, or any other funding agencies previously listed. The sponsors had no role in this publication.
Authors' contributions: All authors made a substantial, direct, and intellectual contribution to the work. LHK designed the study, analyzed and interpreted the data, and drafted the manuscript; DD acquired and managed data and substantially revised the manuscript; ME analyzed and interpreted the data and substantially revised the manuscript; DM contributed to the conception; JSH aided in the design of data analysis and substantiality revised the manuscript; JSL contributed to the conception and aided in the study design and approach to data analysis. All authors read and approved the final manuscript.
Acknowledgements: This author group would like to acknowledge Allison Gustavson, Emma Beisheim-Ryan, Katie Butera, Katherine Seidler, Elizabeth Stanton, Renee Rudys-Shapard and Janell Pisegna individuals for their invaluable contributions to this research project.

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Additionalfile1HIRCaseStudyStaRIchecklist.docx
Additional File 1: Reporting Guidelines and Checklists
AdditionalFile2HIRcasestudyHIRdescription.docx
Additional File 2: Description of High-Intensity Resistance Rehabilitation
AdditionalFile3HIRcasestudystrategydescription.docx
Additional File 3: Description of the Standardized Multicomponent High-Intensity Resistance Rehabilitation Implementation Strategy
AdditionalFile4HIRcasestudyquestionnaires.docx
Additional File 4: Case Study Questionnaires
AdditionalFile5HIRcasestudyqualfactors.docx
Additional File 5: Qualitatively Identified PRISM Constructs and Factors by Site Implementation Success
AdditionalFile6HIRcasestudysiteinitiatedstrategies.docx
Additional File 6: Site-Initiated Implementation Strategy Description and Impact

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Using the Implementation Research Logic Model to Examine High-Intensity Resistance Rehabilitation Implementation in Skilled Nursing Facilities: A Mixed Methods Multi-Site Case Study

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Results

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Background

Methods

Implementation Research Logic Model

Data collection

Quantitative questionnaires

Questionnaires of site implementation

Questionnaires of contextual factors

Qualitative data collection

Data analysis

Mixed method analysis

Results

Site-level implementation

Contextual Factors

Site-initiated implementation strategies and their impact

Provisional implementation processes

1. Overcoming inertia of current practice through salience

2. Overcoming clinician perceived lack of patient compatibility through affirmative experiences

3. Addressing clinician perspective of complexity with session planning

4. Optimizing patient rehabilitation mindset through encouraging environments

Discussion

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