We systematically reviewed interventions that attempted to change staff practice to improve long-term care resident outcomes.
Studies met criteria if they used a control group, included 6 or more nursing home units and quantitatively assessed staff behavior or resident outcomes. Intervention components were coded as including education material, training, audit and feedback, monitoring, champions, team meetings, policy or procedures and organizational restructure.
Sixty-three unique studies were broadly grouped according to clinical domain—oral health (3 studies), hygiene and infection control (3 studies), nutrition (2 studies), nursing home acquired pneumonia (2 studies), depression (2 studies) appropriate prescribing (7 studies), reduction of physical restraints (3 studies), management of behavioral and psychological symptoms of dementia (6 studies), falls reduction and prevention (11 studies), quality improvement (9 studies), philosophy of care (10 studies) and other (5 studies). No single intervention component, combination of, or increased number of components was associated with greater likelihood of positive outcomes. Studies with positive outcomes for residents also tended to change staff behavior, however changing staff behavior did not necessarily improve resident outcomes. Studies targeting specific care tasks (e.g. oral care, physical restraints) were more likely to produce positive outcomes than those requiring global practice changes (e.g. care philosophy). Studies using intervention theories were more likely to be successful. Program logic was rarely articulated, so it was often unclear whether there was a coherent connection between the intervention components and measured outcomes. Many studies reported barriers relating to staff (e.g. turnover, high workload, attitudes) or organizational factors (e.g. funding, resources, logistics).
Citation: Low L-F, Fletcher J, Goodenough B, Jeon Y-H, Etherton-Beer C, MacAndrew M, et al. (2015) A Systematic Review of Interventions to Change Staff Care Practices in Order to Improve Resident Outcomes in Nursing Homes. PLoS ONE 10(11): e0140711. https://doi.org/10.1371/journal.pone.0140711
Editor: Terence J. Quinn, University of Glasgow, UNITED KINGDOM
Received: June 28, 2015; Accepted: September 28, 2015; Published: November 11, 2015
Copyright: © 2015 Low et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: This work was supported by the Dementia Collaborative Research Centres at University of New South Wales, Queensland University of Technology, and Australian National University. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
There are multiple high quality trials and systematic reviews providing evidence for good practice in long-term residential institutions for older people, referred to in many countries as nursing homes and, also known as long-term care homes, homes for the aged, rest homes, residential aged care facilities [1–3]. However, there is often an unreasonable lag between research evidence and practice change . Further, attempts at knowledge translation may not be successful. For instance, after over a decade of extensive promotion of person-centered cultures of care, culture change efforts are becoming widespread in American nursing homes, but it is not clear whether implementation efforts are changing staff and organizational practices, nor whether these practice changes are improving quality of care or resident outcomes .
Barriers to implementation have been identified such as cost, senior leadership resistance, low-innovation culture, low staff education, and high staff turnover . Success factors for implementation include contextualizing the practice change, adequate resourcing, and demonstrating connections between practice change and outcomes .
Implementation science has an important role in bridging the gap between research and practice within health services . There is a vast body of research that focuses on changing the practice of individual clinicians such as general practitioners [9,10], allied health professionals  and nurses . There is less information about how to change the behavior of teams of staff in organizations such as hospitals, health services, and nursing homes, despite evidence suggesting that organizational culture contributes to health care performance [7,13].
Previous systematic reviews have examined whether specific interventions can improve related resident outcomes. For example, reviews have examined the effect of training nursing home staff in dementia care and management of behavioral and psychological symptoms, and the effectiveness of quality systems in improving nursing home quality of care and culture change [14–16] . These reviews described the literature as being of relatively low quality with high possibility of methodological bias. The review of staff training concluded that extensive interventions with ongoing support successfully demonstrated practice change, but there was little evidence for simpler training without reinforcement . The review of quality systems found that results were inconsistent but that there was some evidence that specific training and guidelines can influence resident outcomes . These reviews focused on efficacy of interventions with less emphasis on identifying which interventions or components of interventions contributed to changing practice.
Implementation scientists are increasingly more interested in why practice change interventions succeed or fail and have called for greater use of theory in planning and understanding interventions . Program logic models have also been used to describe how intervention components relate to each other and outcomes [19,20]. Articulating its logic to those delivering and receiving it may also help maintain its integrity during delivery .
This purposefully broad review aims to identify interventions or intervention components to change staff care practices in order to improve resident outcomes.
- To systematically identify and describe studies that have investigated the effects of interventions to change staff practice or care approaches in order to improve resident outcomes in nursing homes;
- To identify interventions or intervention components which lead to successful staff practice or care approach change in nursing homes;
- To identify potential barriers and enablers to staff practice or care approach change in nursing homes.
The search strategy was developed following consultation with an information services university librarian using an iterative process of preliminary searches testing search terms and incorporating new search terms as relevant papers were identified. In addition to our own search terms, our strategy included all relevant MeSH (Medical Subject Heading) terms. Using language (English) and date (1990–5th December, 2013) restrictions and searching titles, keywords and abstracts, we systematically searched the following electronic databases: Ovid MEDLINE, PubMED (from 2012 onwards as up to 2012 would be covered in MEDLINE), Scopus (Health sciences and social sciences), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, and Database of Abstracts of Reviews of Effects. Reference lists of included papers and related reviews were hand searched. The “grey literature” was not specifically searched. Search results were combined using the electronic referencing system Endnote, and duplicate citations were removed.
General search strategy: (“nursing home?” or “long?term care” or “residential care” or “home? for the aged” or “residential facilit*” or “residential aged care”) And (“implementation” or “knowledge translation” or “knowledge transfer*” or “culture change” or “adoption” or “quality improvement” or “dissemination” or “diffusion” or “practice change” or “training” or “champion?” or “opinion leader?” or “educational outreach” or “case conference” or “audit and feedback” or “organisational change” or “organizational change” or “”professional development” or “supervision” or “leadership” or “health plan implementation” or “traditional medical research” or “organi?ational culture” or “organi?ational innovation”) And (“staff” or “carer?” or “management” or “nurse?” or “careworker?” or “manager?” or “personal support worker?” or “personnel” or “caregivers” or “health personnel”).
Two researchers (LFL and JF) independently screened the titles and abstracts and determined whether a study met inclusion criteria. The full text of all articles classified as meeting or possibly meeting inclusion criteria were retrieved and evaluated. Disagreements were resolved by discussion between the two reviewers.
Studies were conducted in nursing homes, i.e. facilities catering for permanent residential care of older people including providing housekeeping, personal care, meals, activities and nursing home. This is distinct from medical facilities primarily delivering medical or palliative treatments, and retirement villages where residents attend to their own personal care and housekeeping.
Randomized controlled trials and quasi-experimental controlled trials were included as recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group .
Only studies with 3 or more sites in each group were included. EPOC recommends only including clustered trials with at least two intervention sites and two control sites. The rationale was that in studies with only one intervention or one control site, the intervention is completely confounded by site characteristics making it difficult to attribute any observed differences to the intervention rather than to other site-specific variables. We extended this requirement to at least three intervention and three control sites in order to reduce the possibility of site-specific confounding and increase generalisability. A study with fewer than 6 sites is unlikely to be statistically powered to take into account site clustering in the analysis. Studies were not restricted based on the number of participants within each site.
Aimed at changing the care practices of staff for the benefit of the residents. The intervention or components of the intervention were not delivered directly to residents by the research team or other external clinicians.
Empirically assessed change in at least one of the following outcomes: change in staff behavior (but not just attitudes or knowledge), change in other staff outcomes (e.g. staff turnover, absenteeism or stress) change in resident clinical outcomes (but not just satisfaction with care). We did not include studies in which the only outcomes were staff attitudes or knowledge as changing knowledge does not necessitate change in behavior [23,24], or those in which the only resident outcome was satisfaction with care as these represent overly an optimistic view of care .
Study data were extracted using standard forms that were based on forms developed by the Cochrane Effective Practice and Organisation of Care Group . Extraction was conducted by one researcher (LFL or JF) and checked by a second researcher (JF, LFL or MM). Study authors were contacted for additional information as required.
Categorising of intervention components.
We categorized interventions via their different components (one intervention could have many components) according to categories and definitions adapted from the Cochrane EPOC group . These were:
- Educational material: written material or a DVD/video or online website
- Training: delivered in person to staff
- Reminders: e.g. postcards, posters—designed to prompt practice
- Audit and feedback: formal monitoring of the performance of staff or the organization which is fed back to them
- Mentoring or support: supervision/consultation/mentoring of staff in teams or individually to support practice change
- Champions: individuals or teams responsible for driving change within the site
- Team meetings: Consensus/multidisciplinary team meetings to discuss issues relating to the clinical domain of practice
- Policy/procedure: a new policy or procedure introduced into the organization (e.g. reporting tool, assessment tool, guideline)
- Organizational restructure: change to the responsibilities of staff or the way care is organized
Barriers and enablers.
Information on barriers and enablers were extracted either where reported as part of a process evaluation, or as part of the discussion section.
Theoretical models of behavior change.
We collected information on theoretical models described as underpinning behavior change strategies. These were differentiated from theoretical models guiding the hypothesized relationship between the intervention and the resident outcomes.
Program logic models.
Program logic models attempt to identify key program components and outcomes and depict how these elements are expected to relate to each other . Program logic models help researchers identify weaknesses in hypothesized causal relationships between intervention components and desired outcomes. Program logic models are also useful in planning evaluations .
Where the program logic was described in a figure or text, this was extracted. Otherwise researchers drew a program logic model based on their interpretation of the description of the study (see examples in Fig 1). We used the program logic model to help us categorize outcomes into staff behavior (behavior that is directly targeted by the intervention), staff indirect outcomes (staff characteristics and behaviors not directly targeted by the intervention such as turnover and stress) and resident outcomes (both directly targeted and indirectly assumed to be impacted by the intervention). We examined these models for weaknesses in the relationships between the intervention and outcomes, as well as staff behaviour changes, or resident outcomes that were implicit but not measured in the evaluation.
Risk of bias.
One reviewer assessed the risk of bias of included studies as outlined in the Cochrane Risk of Bias for EPOC reviews tool  that considers selection bias, performance bias, detection bias, attrition bias, reporting bias and other bias. This risk assessment was checked by a second reviewer and disagreements were resolved through discussion.
Data analysis and synthesis
The purpose of this review was not to evaluate the efficacy of interventions. Within each clinical domains there were no studies with similar intervention components and outcome measures which could be considered for combination in meta-analysis. Hence meta-analyses were not undertaken. Results are presented in narrative form.
Studies were according to the clinical domains in which practice change was targeted. Clinical domains were then ordered according to our subjective judgement of the complexity and difficulty of the behavior change required and are presented in that order from Tables 1 to 12. There is no model or framework for classifying how complex or difficult a behaviour is to change, particularly in an organisational context, however this is intuitively an important factor to consider in this review. In ranking domains by difficulty of behavior change, we considered whether there were salient cues for the new behaviors with cues making change easier, whether past habitual behavior had to be relearnt as this is more difficult than learning a new behavior, whether the practice change required coordination and cooperation between multiple staff members which we ranked as more difficult than when cooperation was not required, and the frequency in which the behaviors occur where more frequent behaviors were harder to change .
The search produced 7572 unique articles, we obtained 211 full text articles and 77 articles were judged to meet inclusion criteria. Two articles were additionally obtained by hand searching reference lists, leading to a total of 79 included articles relating to 63 unique studies. (See Fig 2)
Three studies examined the effect of interventions with staff on the oral health of residents (see Table 1) [28–30]. Two of these were by the same group and tested almost identical interventions in different countries (Belgium and Netherlands) [29,30]. One provided training and toothbrushes , the other two provided a more complex multifactorial intervention (De Visschere et al., 2012, van der Putten et al., 2013).
None of the studies measured whether staff behavior changed. All three reported improvements in residents’ denture plaque, and two also improved dental plaque [28,30]. One study also reported improvements on other oral health conditions . See Table 1.
Hygiene and infection control
The two studies that reported staff behavior found improvements regarding infection control and hand hygiene. This change in staff behavior resulted in improved outcomes for residents in terms of reducing hospitalization relating to meticillin resistant staphylococcus aureus (MRSA) or respiratory outbreaks  but not on prevalence of MRSA . One study reported no impact of the infection control program on resident infections . Staff levels of MRSA were also not shown to be improved in the one study that measured this .
There were two studies that focused on improving residents’ nutrition [34–36] (see Table 3). Both provided training, education materials and supported a change champion. Both studies showed some positive impacts on the nutritional care provided and improvements in some nutritional indicators in residents [35,36] .
Nursing home acquired pneumonia
Two studies used a guideline implementation approach to prevention and management of nursing home acquired pneumonia [37,38] (see Table 4). Both these studies involved staff training, and one supported a nurse to champion the program and materials and reminders . One of the studies also offered staff vaccinations ; this showed improvement in staff influenza vaccination rates, and resident pneumococcal vaccination but no differences between groups on antibiotic use . Neither study found differences in the indirect outcomes for residents of hospitalization or short-term mortality [38,40].
There were two studies with a focus on reducing nursing home residents’ depression (see Table 5) [41,42]. Both provided staff training. Neither study reported staff outcomes. One study found an the intervention improved depression in somatic but not dementia units and indirect effects of improvement in quality of life for both units , however the other study found no impact on depression  nor improvements on the more distal resident outcomes of anxiety, quality of life or pain.
Seven studies focused on appropriate medication use [43–50](see Table 6), most relating to antipsychotic medications. With the exception of , all these studies educated physicians and staff on appropriate medication use and on non-pharmacological strategies to manage clinical conditions. Most studies included other methods in their intervention such as audit and feedback [43,51] and team meetings (i.e. case conferences [44,50,51].
All studies showed improvements in the use of some or all the target medications, and two studies reported no resultant deterioration in resident behavior [44,52]. One study reported both improvements and deteriorations in some resident clinical domains . No studies measured the indirect effects of the programs on staff (i.e. whether they experienced greater stress or perceived workload). Two studies measured effects on indirect resident outcomes and found no effects on falls and wellbeing , or on rates of hospitalization, mortality or change in level of care .
Physical restraint reduction
All these studies measured the impact of training on staff behavior. Two studies reported reductions in physical restraint use by staff without concurrent increase in chemical restraints, or increased falls or injuries in residents [54,55], however one study did not demonstrate overall improvements relative to the control group .
Management of behavioral and psychological symptoms of dementia
There were six studies which attempted to change staff behavior in relation to the management of behavior and psychological symptoms of dementia [57–62](see Table 8). All these involved training and additional intervention components such as mentoring and support [58,59] and reminders [59,62].
Only two of the studies measured whether there was a change in staff behavior in regards to care of people with dementia [58,60]. One study found no changes in the treatment of depression  and one improved communication in pain awareness . One study showed that the intervention had negative impacts on staff stress and perception of supervisory support . However, another study that measured indirect staff outcomes and found benefits for emotional reactions, autonomy and work pleasure, but not for the more distal outcomes of general health and job satisfaction . The effects of the interventions on resident behavior were mixed, with some studies suggesting behavioral improvements [58,59], some studies finding worsening of behaviors [61,62]. One study which measured the indirect resident outcome of quality of life found no impact .
Falls reduction and prevention
Eleven studies examined interventions to change staff care practices with regards to falls reduction and prevention [63–74] (see Table 9). Compared with other clinical domains the studies in this domain tended to be larger in terms of number of sites and participants. With one exception which introduced a computerized measure of fall reporting , all the studies offered training and additional intervention components such as education materials [63,65,66,72,74] hip protectors [63,74], reminder materials [63,70], assessment tools [64,68,71], supported behavior change [66,68], audit and feedback [64,71], champions [64,71,72], and one trained regulatory inspectors . Two studies also encouraged staff to run exercise groups [71,72].
Five of the studies examined whether staff changed their practices though none examined fall prevention activities comprehensively—one reported increases in hips protector use  and two did not [63,69], one found some improvement in documentation relating to falls , one reported reductions in physical restraint use and better care process documentation for falls , and one found increased prescriptions of biphosphonate, calcium and Vitamin D . Of the seven studies which investigated the impact of the intervention on rates of falls [64,65,67–70] three reported a reduction [64,70,73]. Only one of eight studies which looked at rates of fractures or other injuries [63–66,68,69,71,72] found a reduction in at least one type of injury . One study found a reduction in hospitalization related to falls .
Nine studies investigated the impact of interventions to improve care quality [75–83] (see Table 10). With one exception , all studies utilized multi-component interventions which encouraged nursing homes to examine their existing care performance and processes and included other methods to support facilities to change their practices.
All studies included and reported improvements in at least one measure of staff behavior related to quality improvement [75–77,79–82,84,85]. The studies which measured the impact of quality improvement on indirect staff outcomes such as retention rates found no effect [82,83]. Five studies which measured outcomes for residents reported improvements on at least one of these [78,79,81,83,85]. The two which did not improve resident outcomes produced minimal changes in staff behavior [76,77]. There did not appear to be a pattern in type or number of components of interventions and outcomes.
Philosophy of care
Ten studies focused on changing the philosophy or aspects of care culture, such as person-centered care, emotion-oriented care, awareness oriented care and restorative care [86–103](see Table 11). One study offered training only , and one changed staff responsibilities and care procedures . The remaining studies combined training with other intervention components such as mentoring or support [86,87,89,92,97,99,100,102] and audit and feedback [86,89].
Seven out of eight studies that measured whether staff changed their behavior showed at least some improvements [86,90,91,94,96,98,101]. There did not appear to be a pattern in the intervention components that produced successful interventions. Studies that measured indirect staff outcomes reported improvements relating to feelings related to some aspects of work [88,96,101,102], but not on more distal outcomes of health, stress, absenteeism or turnover [92,93,100,101]. Some studies reported benefits on resident behavior [87,89,97,98] functional ability and self-care  and quality of life , however others found no change or a negative effect on behavior [92,100], wellbeing and satisfaction with care [95,100] and resident communication . Generally, studies which had positive outcomes for residents also achieved staff care practice change, however changing staff behavior did not necessitate improved resident outcomes.
Other clinical domains
Single studies were identified which addressed use of advance care directives , pain management , assault reduction , resident to resident mistreatment , and pressure ulcer reduction (see Table 12). Three of these studies had some positive effects for changing staff practices [104,106,107] and the three studies which reported resident outcomes showed some positive results [104,105,107].
Theoretical orientation of practice change component of program
Nine of the eleven studies that reported using a theory in planning the intervention successfully changed at least one aspect of staff care practices. The theories were: Kotter’s eight-step change model , Kitson implementation of evidence based practice framework [35,36,63], precede/proceed model , Roger’s diffusion theory of innovation [37,39,40,108], Bandura’s social learning theory [65,74], adult learning theory , Grol and Wensing’s stepwise approach to implementation , the disease management model , and the theory of planned behavior .
Only three studies explicitly described or presented their program logic or how the intervention was intended to impact the outcomes measured. Zimmerman  provided a clear causal chain (and means of testing it) from staff training through to resident quality of life. Teresi  provided a risk factor model indicating risk factors, process outcomes and distal outcomes. Smith  outlined the components of nursing home staff participation and resident participation in the program and the evaluation methods for each level of participation.
The program logic models that we drew based on the intervention description show that targeted staff practices were often not evaluated (for example in Fig 1 in the Meyer study, staff falls prevention practices were not measured), or only some aspects of practice change were evaluated. The logical link was not always apparent or strong between the intervention elements and some of the indirect staff outcomes, particularly turnover and absenteeism, and resident outcomes such as quality of life.
Translating research-demonstrated programs
Three studies reported implementing with staff a program which had previously been shown to be effective when delivered by expert clinicians [38,61,66]. These were in the areas of NHAP guideline adherence, fall-related injury prevention and dementia care. There were also two studies which were larger implementation projects of a fracture prevention program which was originally shown to be effectively delivered by staff [71,72,109].
Potential barriers and enablers to change
Some studies reported barriers and enablers as part of a formal process evaluation [e.g.s 54,105,110] and others reported barriers as part of the discussion [e.g.s 53,92,107]. Many barriers and enablers related to staff—these appeared to be factors that impact on staff practices in general as well as in the implementation of new practices (e.g. high turnover, absenteeism, high workload, low education, and communication/support from senior staff). Organizational and system issues cited seemed to be more specific to the implementation of the new practices e.g. insufficient funding, logistical issues and infrastructure difficulties associated with implementation. Finally, there were several studies that mentioned barriers and enablers that were related to the resident’s high care needs or attitudes of residents and/or families (see Table 13).
Risk of bias (see data in S1 Appendix and Tables 1–12)
Given the nature of staff behavior change interventions, the allocation to control and intervention groups were not blinded from almost all staff participant groups. Some studies did not use a randomized design, and randomized trials often did not report on their randomization method. Other common biases were incomplete outcome data not being adequately addressed and assessors not being blinded to group allocation. Most studies took some care to protect against contamination and we were unable to detect selective outcome reporting. Baseline characteristics and outcomes were usually similar or controlled for to the intervention group. However, studies which were rated as having multiple risks of bias were not more likely to report a positive outcome.
There are no “magic bullets” to change staff care practices in order to improve resident outcomes. We did not find that any single intervention component (e.g. champions, or audit and feedback), or combination of components consistently resulted in improvements in staff practices within each clinical domain, nor did increasing the number of intervention components.
Studies that did not change the targeted staff behavior tended to also not improve resident outcomes, and indirect staff outcomes were rarely improved as a result of interventions aimed at improving care of residents.
Studies in clinical domains involving more specific care practices (i.e. hygiene, oral care, appropriate prescribing, and physical restraint reduction) tended to have a higher proportion of “successful” studies compared to domains requiring more global practice changes (i.e. dementia care, falls, quality improvement, philosophy of care). Possible reasons for these differences are:
- The staff behaviors were relatively easier to target and easier to change, such as those which require the changes during specific care practices by individual staff, rather than more coordinated changes between staff across multiple care practices
- The target outcomes were easier to measure (and therefore successes and failures were easier to observe)
- The primary outcome of the intervention was staff behavior which is more directly influenced by the intervention components, rather than resident outcomes
- There was a better established evidence base between specific care practices and resident outcomes (e.g. fracture prevention program by , or between implementation strategies and changing that behavior in another setting (e.g. hygiene in hospitals )
In many studies the logical relationships between interventions and measured staff and resident outcomes were not clear. Using a program logic model may help better match intervention components and outcomes in designing the intervention and measurements, as well as assisting with maintaining program integrity during delivery. The program logic model also can guide choice of outcome measures, measuring resident outcomes address questions of effectiveness, and may help researchers and services wanting replicate the intervention in their own setting understand the how practice changes were achieved . When staff behavior is not measured, it is not clear whether the program has been unsuccessful because of implementation error or because the staff behavior has changed, but has not brought about the desired improvement in residents .
These results support the notion that using theory to plan implementation strategies will increase the success of translating research into practice change . Theories are seldom used, possibly because of the proliferation of theories, models and frameworks, many with limited empirical validation . Nilsen has suggested that since implementation is multifaceted and complex it is unlikely that a single theory can guide all endeavors in the field, however those of us attempting to change practice are left with little guidance on how to choose a theory to guide our implementation.
Barriers and enablers for staff behavior change were often discussed in the context of failed or suboptimal interventions; addressing these proactively as part of the intervention design may increase the chances of success . Common barriers at the staff level were high turnover or absenteeism and high workload, and at the organizational level, were lack of resources and funding, infrastructure and software difficulties and other logistic difficulties such as time scheduling and organization. Barriers were consistent with other research relating to practice change in nursing homes [117,118]. Researchers should consider barriers from staff, organizational and resident and family perspectives, as well as the external context.
Strengths and limitations
The inclusion criteria were designed to include higher quality studies; however we may have inadvertently missed a high quality study because of how we operationalized inclusion criteria. There may be a risk of publication bias towards reporting of studies with positive effects within the literature and also of selective reporting within studies—we were unable to assess publication bias statistically as the range of outcomes within each group of studies meant that it did not make sense to combine them in a forest plot. The patterns of results described in this review should be considered with this limitation in mind.
We included a broad range of staff behavior changes so that we could observe the common ingredients for successful practice change across interventions. This was challenging because of the large number of studies included. We decided to present the studies grouped according to clinical domains, we examined groupings according to intervention components, however these were difficult to interpret and not very meaningful. The review team ranked difficulty and complexity of behavior change of clinical domains subjectively.
This review did not look at the ‘dose’ of training or other components, just whether these were provided. This was not examined because the length and frequency of training were usually described however other aspects such as the number of staff trained and style of training (e.g. didactic, interactive) were not routinely reported and may also be important in influencing the impact of training. We attempted to examine fidelity of implementation of the interventions, however this was poorly described or not described at all in many studies, such that is it not known whether the interventions were delivered as described in many studies.
Practice change and research implications
Researchers, clinicians and service providers contemplating programs requiring staff behavior change in nursing homes should consider: a multifactorial program rather than training alone, investigating and addressing barriers and enablers for their program, using a theory and program logic to design the intervention to ensure that components that target the specific behaviors they want to change and considering motivation as well as knowledge and skills, conducting a process evaluation based on the theory and program logic so as to understand how and why the program succeeds or fails, and planning their statistical analyses to take into account clustering and incomplete datasets.
Future research could consider staff motivations in achieving and sustaining behavior change, distinct from delivery of the knowledge and skills required for the change. It would also be useful to develop of a list of common barriers and possible solutions in nursing home practice change, as well as a framework for categorizing the difficulty or complexity of behavior change, for individuals and in an organizational context. The methodology for systematic reviews of efficacy (examining the relationship between a single intervention and single outcome) is well developed, similar methodological development is required for systematic reviews of complex interventions  and when outcomes relate to implementation success.
We thank Monica O’Brien, information services librarian at University of New South Wales library for advice on the search strategies for online databases.
Conceived and designed the experiments: LFL JF. Performed the experiments: LFL JF. Analyzed the data: LFL JF MM. Wrote the paper: LFL JF BG Y-HJ CE-B MM EB.
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