The majority of the data from the FGDs corresponded to three of the seven CICI framework domains: 1) Political, 2) Epidemiological, and 3) Geographical. Within each of these three domains, specific themes surfaced in the FGDs, henceforth referred to as sub-domains of the context. Within each sub-domain, we differentiate between the existing and required elements noted by HCPs. Existing elements refer to components of the context already existing in the facility that would support the implementation of this model, whereas required elements were those identified by HCPs as needed in order to successfully proceed with the implementation. See Table 2 for a summary of the context assessment with the domains, sub-domains, and the key elements identified.
1. Political domain
The predominant proportion of the data pertained to the Political domain of the context, which focuses on the distribution of power, assets, and interests within a population, and also includes the health care system and its accessibility with respect to service delivery, leadership, governance, and human resources (10). Most data within this domain was related to two key contextual aspects within the CICI framework: power and assets. Power relates to the distribution of itself, between those in leadership positions and staff, and also within a team, such as power differences between team members. The distribution of power within a team has an impact on roles, such as how the roles are carried out. Power also relates to how leadership is carried out, especially with regards to communication, and how leadership is needed to overcome barriers to model implementation. Assets relate to access to resources, which could include human resources, such as staffing, or knowledge, examples of which include training or access to training.
The political domain was organized into five sub-domains: 1) Teamwork; 2) Facilitation; 3) Resources; 4) Communication; and 5) Preparedness for Change. These sub-domains and their corresponding existing and required elements of the context specific to this case study, are described in detail below.
1.1. Teamwork: Everyone needs to be on the same page
Teamwork was identified by participants as a critical component of the political domain, essential for the next stage of the implementation. Participants identified two existing elements already in place at this facility which would facilitate the implementation: the use of team rounds and effective teamwork. One participant observed that the use of rounds was an existing element which allowed the team to monitor patient goals and progress:
We have rounds once a week with the PT/OT, clinical leads, staff, recreational therapist to discuss how the patient’s doing and what goals we need to move forward. It helps. [Focus group (FG) 3, Participant (P) 19, RPN]
Interdisciplinary rounds were noted as useful to enhance communication, resolve discrepancies of approach among team members, and to ensure all team members remain up to date with patients’ care plans and rehabilitation goals.
In addition to team rounds, a participant remarked that good teamwork allowed them to effectively provide care to a patient with responsive behaviours:
We have a patient here that has a lot of behaviours but we all team up to provide care for him and he has his primary RPN, but if that person is on break, we’ll make sure that he’s being monitored closely and that his tabs monitor’s are applied, and so we take care of each other that way. (FG3, P21, RPN)
This collaboration between members of the team, including the assistance from colleagues when the primary health care provider was not available, is an existing element that supports the implementation of the model of care.
Two required elements to strengthen the system before moving on to the next phase of implementation were identified: the need to understand each team member’s role in patient mobilization and the need for a consistent interdisciplinary approach. The need for role clarity, in particular with respect to who is responsible for the mobilization of patients, emerged as an element that could strengthen the success of implementing the new model of care:
We need to mobilize people more, people are in wheelchairs, it was very frustrating for me because obviously, that’s what we want, but… we all need to be on board and it’s not just the physio’s job. (FG1, P8, PT).
Although participants commented on having effective teamwork, inconsistencies remained in terms of how individuals perceived their roles and carrying out certain rehabilitation activities. Another required element identified was the need for a person-centred approach involving multiple HCPs. One participant weighed in on the importance for all team members to embrace a consistent, person-centered team approach:
It all has to do with an interdisciplinary type of approach, it’s not solely one person’s responsibility to be walking a patient to the meal. It’s not the PT role. It’s everybody’s role and it comes back to the whole common goals. And it’s not just the OT’s role to do ADLs [activities of daily living], nursing can do that as well. (FG1, P10, OT)
Thus, another element that potentially could improve the context in preparation for implementing the next stage of the rehabilitation model is a consistent interdisciplinary approach. In order for all team members to be on the same page, the continuation of weekly rounds and effective teamwork (existing elements), and the introduction of role clarification and a consistent interdisciplinary approach (required elements), were recommended.
1.2 Facilitation: Imperative for change
Facilitation was identified by participants as being critical to bringing about organizational change through the translation of knowledge into practice. One existing element within the organization, and one required element were identified as important factors to support progress towards the next phase of implementation. An existing element included instances where individual team members provided facilitation to support a change in care. A participant provided an example of a team member who not only verbally informed but also physically demonstrated to a colleague how to carry out a new way of transferring a patient:
I’m a part-timer so when I do come in I’ve noticed that OT [occupational therapist] will spot me and go, “Oh, you’re here today. You have that patient, so let me just update you on her transfer status.” Then he’ll actually bring me down to the room and we’ll do the transfer together so that I have better understanding of how that person pivots, how they transfer exactly like step by step, which is very helpful. (FG3, P16, RPN)
The updating of the participant on the transfer status of the patient, and the demonstration of the transfer facilitated the participant’s uptake of a safe, up-to-date transfer.
A required element identified was the need for a dedicated facilitator to translate knowledge into practical change. Several participants remarked that this type of facilitator role was required to integrate new knowledge (strategies used outside this facility) into practice within the local setting:
I think the idea of a facilitator to help us create what we need, using strategies from outside, but adapting it to what we need here. Someone who’s flexible and can help us work through the challenges of what we face in this system. (FG2, P11, OT)
Participants identified the need for a focused resource available for the duration of the implementation project to assist with translating newly acquired knowledge into daily practice changes within patient care. Therefore, in order to enable the facilitation required to support organizational change, ongoing patient-based facilitation by individual team members as well as the availability of a dedicated organizational resource for facilitation, such as a facilitator, would be needed.
1.3 Resources: Quality and quantity matter
The availability of resources, including adequate staffing and continued access to knowledge by all staff was a recurrent topic in the discussions. One existing element already in place within the organization and two required elements were mentioned as essential to implement this model of care in this context. As an existing element, FGD participants described how the recent addition of a staff member, a physiotherapist, to their team was an important factor to supporting the delivery of quality care, which allowed for a more manageable amount of work:
It’s always time management …running after it and having to chase after it, and I think things are going to be better now that we have some more staffing here. We have another therapist with us now so workload will be a little bit more manageable. (FG1, P8, PT)
Participants expressed that having a manageable daily workload would support the upcoming changes at the facility.
Although having an additional staff member was highlighted as an important existing element, FGD participants identified the need for even further staffing increases as one of two required elements for future implementation. Participants consistently reported on challenges they faced because of inadequate staffing, and the need for more team members, especially in order to make rehabilitation available on evenings and weekends. When asked about the type of resources required to provide care to patients with CI, participants noted the need for more nursing staff as well as more allied health staff, due to the rehabilitation needs of the patients:
And I think having more support. Like I think that often right now we’re having no rehab assistance, no rehab OT/PT available on weekends. And evenings (FG4, P23, RN)
Thus, from the perspective of participants, a staffing complement to match patient care needs would enable the provision of better-quality rehabilitative care. The second required element that emerged from the FGDs revolved around the need for access to knowledge for all team members. As one staff member described, this related specifically to making education available to those who work part-time, night shift, or weekends:
…All of us had the opportunity to participate in the training and a lot of nurses did too, but I’m not sure if people who work night shift, people who work part-time and doing weekends they got that training too because many times – majority of times we’re here only seven hours a day working with the patient but the majority of time it’s the nurses who are with the patient they keep rotating. Their shift changes, not like ours which is steady. So, probably that will help if everybody got that training and also that’ll help them feel like part of the team. (FG1, P4, PT)
Providing training to staff from all shifts and disciplines would allow for a consistent knowledge base, thus building capacity and promoting the uptake of the next stage of the implementation of the rehabilitative model. Thus, ensuring availability of required resources for teams, achieved through adequate staffing and equitable access to knowledge, is recommended to improve the context in preparation for the next stage of implementation.
1.4 Communication: Effective information sharing to enhance care delivery
Communication was recognized as a critical consideration for the implementation of a new model of care. One existing element and one required element emerged as important for implementation preparedness. An existing element involved the use of written documentation, such as goal posters, care plans, and whiteboards. This participant identified the use of care plans to share updates regarding a patient’s status:
Our physio team is usually pretty good with assessing transfers and then they let us know what we’re going to do and they update the care plan. (FG3, P19, RPN)
This example demonstrates how the use of care plans to record and communicate information is a current approach within the facility that can be leveraged for future implementation of the model of care.
To further support preparedness for implementation, one required element was identified by participants. The need for in-person communication – beyond email – for use in conveying changes in processes was highlighted as an opportunity:
People think the easiest way is to communicate through email, but a lot of times it’s not the best way. It’s not – it needs to be explained in person. (FG3, P22, RPN)
Participants observed that general or update emails can be ineffective as they do not promote the asking of clarification questions and thus can limit the use of new resources or uptake of processes that are communicated; an increase in face-to-face communication can facilitate clarification in the form of questions if the need arises. As such, communication is integral to preparing the local context for implementation and would be enabled through the consistent use of both in-person interactions and written documentation.
1.5 Preparedness for change: At all levels
Preparedness for change is the final sub-domain within the political domain. One existing element and one required element were identified as important means to support the implementation of the rehabilitation model. A positive attitude to new initiatives was recognized:
I think we’re always open to trying new things, …I feel like we’re always evolving here and it’s really good. (FG2, P14, RD)
The staff’s willingness to embrace change was noted as an important factor for the implementation of a new model of care. The need for organizational leadership to create a vision and an action plan at the facility level emerged as a required element to bring about organizational practice change. One participant reflected on how there is a need for a leader to take action:
Somebody needs to say “Okay, you guys over there and you guys over there, let’s meet in the middle”. Because we'll sit and we’ll have these great discussions about things and then reach no conclusion. There’s no action plan, …it’s just let’s discuss all the problems and then leave the room. So lots of great ideas that float around. (FG2, P13, OT)
Leadership to provide a vision for a plan of action and to coordinate how to bring about change would also enable the success of the next implementation phase. Therefore, the staff’s willingness to change and the need for leadership to take action at the facility level were identified as essential for successful program implementation.
2. Epidemiological domain
The epidemiological domain, although not as frequently mentioned by participants as the political domain, was also relevant in terms of the context. The epidemiological domain involves the distribution of diseases or conditions, the attributable burden of disease, and the determinants of population needs (10). The key contextual aspect from this domain was the attributable burden of disease, which includes knowledge related to diseases, including clinical presentation, health management, and care needs.
Within the Epidemiological domain, there is one prominent sub-domain: Caring for Persons with Cognitive Impairment. This sub-domain, including its existing and required elements are detailed in the following section.
2.1. Caring for persons with cognitive impairment: It’s not one size fits all
An individualized, person-centred approach to care was identified by participants as a central tenet of this sub-domain. Participants highlighted that individuals with CI, specifically delirium and dementia, have unique needs that require a tailored response. Two existing elements and two required elements were identified. Existing elements consisted of the use of specific models of care and family involvement. The use of known care models was an existing element within the context that supported management of this patient population, as highlighted in the following quote:
I’ve done gentle persuasive approach training and I find that’s been pretty useful. I know that that has come out in the last three years or so…that’s helped me work with patients with behaviors and dementia. (FG3, P21, RPN)
Thus, the provision and use of an effective model of care for the care of persons with CI would be helpful in the implementation of a rehabilitation model. Likewise, leveraging family involvement in care delivery emerged as an important supporting element existing within this context:
Especially with dementia because they [the family] can give you tips on what they know works and a little bit of their history …[I] had a few patients that were quite challenging behavior wise and even involving the family to bring in personal belongings and stuff to help the patient feel like it’s more like their home environment helped with some of the behaviors and the anxiety. (FG3, P22, RPN)
Families provide knowledge and context about persons with CI for HCPs, enabling an individualized approach to care. Using effective care models and including families as partners in care would serve to support the next implementation phase.
In anticipation of meeting the specialized care needs of this population, participants identified two required elements that would further support population-specific, individualized care delivery. For patients with dementia, for example, these included incorporating familiarity and a routine into processes of care, as demonstrated in the following quote:
I feel like that type of patient [with dementia] that we’re focusing on needs routine, needs a familiar face, needs a schedule. They would thrive on that and needs certain prioritizing. (FG1, P2, Rehabilitation Assistant)
The use of routines could assist in the provision of quality care to patients with CI and support the next phase of implementation. Moreover, the need for an individualized approach in patients with dementia and delirium was identified as a second required element, as highlighted in the following quote:
In acute care there’s that focus and everyone has that same level of knowledge, but here those patients will come in and they'll be mixed with everybody else. They’re not necessarily going to be in a pocket. So…you have to shift your mindset between patients, that this patient doesn't need what this patient needs, and I feel like a lot of times there’s a bit of a one size fits all kind of approach here. (FG2, P11, OT)
Participants identified that in this context there needed to be a shift in mindset, from the one-size-fits all approach, to a more individualized approach, in order to provide effective care to patients with cognitive impairment. Therefore, the use of known models of care, involvement of family members, incorporating routine and familiarity, and an individualized care approach emerged as important elements to support the provision of care to persons with cognitive impairment, and to enable the next implementation phase.
3. Geographical domain
The third domain that emerged as significant for consideration within the context was the Geographical domain, understood as the broader physical environment, landscapes, and resources, including infrastructure, that are available in a specific setting (10). Infrastructure was a key aspect of this domain, related to the one sub-domain identified in the analysis, the facility’s physical layout.
3.1 Physical layout: Impact of design on care delivery
The physical layout of the rehabilitation environment was identified as having a significant impact on care delivery and potentially affecting the next phase of the implementation. One existing element and one required element were identified. Participants identified that the location of the dining room, which was part of the physical environment, was leveraged in order to incorporate additional therapy activities during the day:
Everyone does go to the dining room for meals. Breakfast, lunch and dinner they go to the dining room. Ideally with everybody if they are able to ambulate with the required assistance to and from meals as part of their therapy. (FG1, P1, PT)
As the dining room was at a distance for the patients, the design of the unit facilitated patients ambulating more often, which facilitated their recovery.
However, one element of the physical layout required a change as was identified by numerous participants. Within the current geographical context, therapy and nursing were described by HCPs as being siloed from one another, ultimately impacting care delivery. Nursing staff had their station while the allied health care team charted in a different location. Therefore, the full team did not see each other very often. As such, participants identified that re-designing the unit’s workspace to support staff collaboration would be an important required element for implementation:
So maybe just being more incorporated, being closer to being on the floor, maybe that would just help to influence people, and people, like other staff, would be able to influence us and maybe it would make change smoother. (FG1, P7, OT)
Bringing team members closer in proximity to each other would enable smoother team efforts to provide care to patients. Therefore, maximizing the use of the current physical environment to provide care and enabling the modifications to the layout to bring team members closer together were identified as ways to support the next implementation phase.