‘On Your Mark’: Operationalizing a Readiness for Change Module in the SHIFT Intervention

ABSTRACT Background Readiness for change (R4C) is an important antecedent of care practice change and is linked to a range of implementation and effectiveness outcomes. We describe the creation, piloting, and evaluation of R4C activities intended to help nursing home (NH) teams implement a quality improvement intervention. Methods We developed and operationalized a R4C module with activities conducted with NH leaders during intervention recruitment. An implementation pilot was conducted in three NHs and evaluated using a mixed methods process evaluation guided by Proctor’s (2011) implementation outcomes framework. Results R4C activities were feasible, acceptable, and delivered with fidelity. The approach promoted readiness among senior leaders, but not among front-line teams. Results also showed (1) R4C activities are closely tied to other variables (e.g., NH leadership facilitation) that influence implementation, and (2) core R4C components (i.e., change efficacy) can emerge during an intervention, pending teams’ perceived success Discussion We suggest conducting R4C activities with all of those involved across an organization who have a role to play in change implementation. Findings also reveal challenges associated with isolating the effects of ‘pre-intervention’ R4C activities on intervention implementation and success. Pilot results will inform a larger-scale quality improvement study. Trial registration Registered at ClinicalTrials.gov (ID NCT03426072 ) on July 18, 2022. KEY MESSAGES REGARDING FEASIBILITY What uncertainties existed regarding the feasibility? While ‘readiness for change’ has been identified as an important lever for implementation of evidence-informed practice change, there is little in the published literature regarding how to operationalize of R4C to promote uptake of practice change initiatives. There is also uncertainty regarding ‘implementability’ (feasibility, acceptability, appropriateness, fidelity) of R4C activities in complex care settings What are the key feasibility findings? Up-front activities requiring a few hours of a facility leader’s time, designed to gauge and also operationalize and promote readiness for change were both feasible and acceptable and were delivered with fidelity. Facility leaders showed less fidelity enacting the intervention support and communication roles targeted by the R4C activities. A ‘broken telephone’ scenario existed where senior leaders did not convey to unit leaders what their project roles entailed. What are the implications of the feasibility findings for the design of the main study? Our results suggest that it is necessary to actively target R4C activities directly to all organizational members involved in the practice change initiative. Failure to promote linkages and role clarity across participants at different levels of an organization makes it likely that change actors will remain unsure of their role in the change initiative. The design of the main study ultimately included two additional R4C focused meetings (one to bring senior and team sponsors together, one to bring team sponsors and team members together) to promote greater role clarity and enhanced project preparation.

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