Comparing effects of two higher intensity feedback interventions with simple feedback on improving staff communication in nursing homes—the INFORM cluster-randomized controlled trial

Abstract

Background Effective communication among interdisciplinary healthcare teams is essential for quality healthcare, especially in nursing homes (NHs). Care aides provide most direct care in NHs, yet are rarely included in formal communications about resident care (e.g., change of shift reports, family conferences). Audit and feedback is a potentially effective improvement intervention. This study compares the effect of simple and two higher intensity levels of feedback based on goal-setting theory on improving formal staff communication in NHs. Methods This pragmatic three-arm parallel cluster-randomized controlled trial included NHs participating in TREC (translating research in elder care) across the Canadian provinces of Alberta and British Columbia. Facilities with at least one care unit with 10 or more care aide responses on the TREC baseline survey were eligible. At baseline, 4641 care aides and 1693 nurses cared for 8766 residents in 67 eligible NHs. NHs were randomly allocated to a simple (control) group (22 homes, 60 care units) or one of two higher intensity feedback intervention groups (based on goal-setting theory): basic assisted feedback (22 homes, 69 care units) and enhanced assisted feedback 2 (23 homes, 72 care units). Our primary outcome was the amount of formal communication about resident care that involved care aides, measured by the Alberta Context Tool and presented as adjusted mean differences [95% confidence interval] between study arms at 12-month follow-up. Results Baseline and follow-up data were available for 20 homes (57 care units, 751 care aides, 2428 residents) in the control group, 19 homes (61 care units, 836 care aides, 2387 residents) in the basic group, and 14 homes (45 care units, 615 care aides, 1584 residents) in the enhanced group. Compared to simple feedback, care aide involvement in formal communications at follow-up was 0.17 points higher in both the basic ([0.03; 0.32], p = 0.021) and enhanced groups ([0.01; 0.33], p = 0.035). We found no difference in this outcome between the two higher intensity groups. Conclusions Theoretically informed feedback was superior to simple feedback in improving care aides’ involvement in formal communications about resident care. This underlines that prior estimates for efficacy of audit and feedback may be constrained by the type of feedback intervention tested. Trial registration ClinicalTrials.gov (NCT02695836), registered on March 1, 2016

Examining fidelity in the INFORM trial: a complex team-based behavioral intervention

“…The main trial results showed a statistically significant increase in care aides' involvement in formal team communications about resident care in both the basic and enhanced assisted feedback arms compared to the Simple Feedback arm. However, no differences were observed between the basic and enhanced-assisted feedback arms [12].…”

“…Study arms had few differences in the extent of fidelity delivery, receipt, and enactment. This helps us understand IN-FORM trial results: basic-and enhanced-assisted feedback arms had significantly higher follow-up team communication scores than the simple feedback arm, but the two assisted feedback arms did not differ in scores [12].…”

“…There is, however, little in the published literature regarding fidelity in complex behavioral interventions [6]. The INFORM study [11] (Improving Nursing Home Care Through Feedback On perfoRMance data) is a complex three-arm behavioral trial designed to increase the involvement of unregulated care aides in formal team communications about resident care in nursing homes [12]. This paper reports on a mixed-methods study that examines trial fidelity in IN-FORM and explores the relationship between fidelity, study arm, and the trial's primary outcome-care aide involvement in formal team communications about resident care.…”

Sustained effects of the INFORM cluster randomized trial: an observational post-intervention study

“…While care aide involvement in formal team communications about resident care was our primary study outcome, INFORM is designed to be tailorable to address any of a wide variety of possible outcomes (e.g., care staff quality of work-life, leadership practices, or resident outcomes). We published the methods of INFORM in a trial protocol [ 13 ] and subsequently published results on INFORM’s effectiveness [ 14 ] and the impact of intervention fidelity on intervention effectiveness [ 15 ]. This study addresses an important additional aim outlined in our trial protocol [ 13 ]: to assess longer-term effects of INFORM.…”

“…Results showed [ 14 ] that care aide involvement in formal communications about resident care at follow up was 0.17 points higher in both the basic (95% confidence interval [CI]: 0.03; 0.32, p = 0.021) and enhanced study arms (95% CI 0.01; 0.33, p = 0.035), compared to simple feedback—with no differences between the study arms with the highest (enhanced) and mid-level (basic) intensity. Intervention fidelity was moderate to high, and higher fidelity enactment was associated with larger improvements in formal team communications [ 15 ].…”