Adapting Strategies for Optimal Intervention Implementation in Nursing Homes: A Formative Evaluation

Background and Objectives: Nursing homes pose unique challenges for implementation of research and quality improvement (QI). We previously demonstrated successful implementation of a nursing home-led intervention to improve relationships between frontline staff and residents in 6 U.S. Department of Veterans Affairs (VA) Community Living Centers (CLCs). This article discusses early adaptations made to the intervention and its implementation to enhance frontline staff participation. Research Design and Methods: This is a formative evaluation of intervention implementation at the first 2 participating CLCs. Formative evidence - including site visitors' field notes, implementation facilitation records, and semistructured frontline staff interviews - were collected throughout the study period. Data analysis was informed by the Capability, Opportunity, Motivation, and Behavior model of behavior change. Results: Adaptations were made to 5 a priori intervention implementation strategies: (a) training leaders, (b) training frontline staff, (c) adapting the intervention to meet local needs, (d) auditing and providing feedback, and (e) implementation facilitation. On the basis of a 6-month implementation period at the first CLC, we identified elements of the intervention and aspects of the implementation strategies that could be adapted to facilitate frontline staff participation at the second CLC. Discussion and Implications: Incremental implementation, paired with ongoing formative evaluation, proved critical to enhancing capability, opportunity, and motivation among frontline staff. In elucidating what was required to initiate and sustain the nursing home-led intervention, we provide a blueprint for responding to emergent challenges when performing research and QI in the nursing home setting.