title: Sustaining complex interventions in long-term care: a qualitative study of direct care staff and managers.
abstract: BACKGROUND
  Little is known about the sustainability of behavioral change interventions in long-term care (LTC). Following a cluster randomized trial of an intervention to improve staff communication (CONNECT), we conducted focus groups of direct care staff and managers to elicit their perceptions of factors that enhance or reduce sustainability in the LTC setting. The overall aim was to generate hypotheses about how to sustain complex interventions in LTC.
  
  
  METHODS
  In eight facilities, we conducted 15 focus groups with 83 staff who had participated in at least one intervention session. Where possible, separate groups were conducted with direct care staff and managers. An interview guide probed for staff perceptions of intervention salience and sustainability. Framework analysis of coded transcripts was used to distill insights about sustainability related to intervention features, organizational context, and external supports.
  
  
  RESULTS
  Staff described important factors for intervention sustainability that are particularly challenging in LTC. Because of the tremendous diversity in staff roles and education level, interventions should balance complexity and simplicity, use a variety of delivery methods and venues (e.g., group and individual sessions, role-play/storytelling), and be inclusive of many work positions. Intervention customizability and flexibility was particularly prized in this unpredictable and resource-strapped environment. Contextual features noted to be important include addressing the frequent lack of trust between direct care staff and managers and ensuring that direct care staff directly observe manager participation and support for the program. External supports suggested to be useful for sustainability include formalization of changes into facility routines, using "train the trainer" approaches and refresher sessions. High staff turnover is common in LTC, and providing materials for new staff orientation was reported to be important for sustainability.
  
  
  CONCLUSIONS
  When designing or implementing complex behavior change interventions in LTC, consideration of these particularly salient intervention features, contextual factors, and external supports identified by staff may enhance sustainability.
  
  
  BACKGROUND
  ClinicalTrial.gov, NCT00636675.
authors.affiliation: Duke University School of Medicine, Box 3003 DUMC, Durham, NC, 27710, USA. cathleen.colonemeric@duke.edu.|Durham VA Geriatric Research Education and Clinical Center, 508 Fulton St., Durham, NC, 27705, USA. cathleen.colonemeric@duke.edu.
authors.forename: Cathleen
authors.initials: C
authors.lastname: Colón-Emeric
authors.affiliation: University of North Carolina School of Nursing, Carrington Hall CB #7460, Chapel Hill, NC, 27599, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Toles
authors.affiliation: Duke University School of Nursing, 307 Trent Dr, Durham, NC, 27710, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Cary
authors.affiliation: Duke University School of Nursing, 307 Trent Dr, Durham, NC, 27710, USA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Batchelor-Murphy
authors.affiliation: Duke University School of Nursing, 307 Trent Dr, Durham, NC, 27710, USA.
authors.forename: Tracey
authors.initials: T
authors.lastname: Yap
authors.affiliation: Duke University School of Nursing, 307 Trent Dr, Durham, NC, 27710, USA.
authors.forename: Yuting
authors.initials: Y
authors.lastname: Song
authors.affiliation: Duke University School of Medicine, Box 3003 DUMC, Durham, NC, 27710, USA.|Durham VA Geriatric Research Education and Clinical Center, 508 Fulton St., Durham, NC, 27705, USA.
authors.forename: Rasheeda
authors.initials: R
authors.lastname: Hall
authors.affiliation: Duke University School of Nursing, 307 Trent Dr, Durham, NC, 27710, USA.
authors.forename: Amber
authors.initials: A
authors.lastname: Anderson
authors.affiliation: Duke University School of Nursing, 307 Trent Dr, Durham, NC, 27710, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Burd
authors.affiliation: University of North Carolina School of Nursing, Carrington Hall CB #7460, Chapel Hill, NC, 27599, USA.
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Anderson
mesh_terms: D000293:Adolescent; D000328:Adult; D003142:Communication; D005260:Female; D017144:Focus Groups; D006282:Health Personnel; D006801:Humans; D008134:Long-Term Care; D008297:Male; D008875:Middle Aged; D009735:Nursing Homes; D010559:Personnel Management / Q000379:methods*; D015397:Program Evaluation; D036301:Qualitative Research; D000078329:Workforce; D055815:Young Adult
keywords: Behavior change; Long-term care; Nursing education research; Qualitative research; Quality improvement; Sustainability; System intervention