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Implementation of interventions to maintain and promote the functional mobility of nursing home residents – a scoping review

BMC Geriatrics volume 23, Article number: 600 (2023) Cite this article

Abstract

Background

To provide an overview of the available evidence on the implementation of direct and capacity-building interventions to promote and maintain the functional mobility of nursing home residents.

Methods

We conducted a scoping review following the methodological guidance for the conduct of scoping reviews as described by the Joanna Briggs Institute. We searched for studies in MEDLINE (via PubMed) and CINAHL (via EBSCO). We conducted a qualitative content analysis of the included studies with deductive categories based on the Consolidated Framework for Implementation Research (CFIR).

Results

Ultimately, we included 8 studies on direct interventions, 6 studies on capacity-building interventions, and 2 studies on both types of interventions in our review. Seven studies provided evidence on implementation strategies comprising discrete as well as multifaceted, multilevel strategies. Most of the studies did not systematically evaluate the strategies but remained at a descriptive level. All 16 studies provided evidence of influencing factors. We identified 32 of the 37 influencing factors of the CFIR. The five most frequent influencing factors were available resources (n = 14), access to knowledge and information (n = 12), patient needs and resources (n = 10), knowledge and beliefs about the intervention (n = 10) and compatibility (n = 9).

Conclusions

The available evidence on the implementation of functional mobility interventions in nursing homes is rather limited. This emphasizes the need for further research. Regarding implementation strategies, the systematic evaluation and further development of the reported promising approaches might be a starting point.

Peer Review reports

Background

Functional mobility is an essential precondition for independence [1,2,3] and autonomy [3, 4] in many areas of life. It is important for social participation [5, 6], quality of life [7,8,9,10,11] and subjective well-being [10] as well as for preventing the decline of physical health [12]. In turn, immobility leads to negative consequences, such as negative health outcomes [12,13,14], increased risk of falls [9, 12, 15], and increased healthcare utilization [12]. Apart from cognitive disorders, immobility is one of the main causes of care dependency [12, 16].

Most of these negative consequences frequently occur for nursing home (NH) residents, and thus, the decline of physical performance is also evidently associated with them [17, 18]. Given this situation, maintaining and enhancing functional mobility are important factors for preventing health restrictions and increasing the care dependency of NH residents. Thus, maintaining and enhancing functional mobility are pivotal tasks of professional care in NHs [16, 19].

Many interventions are available to enhance functional mobility and to prevent the functional decline of residents. In addition to interventions that focus directly on the behavior of the person whose functional mobility is to be maintained or enhanced (e.g., exercise programs, walking programs), there is an increased awareness that interventions that aim to improve organizational capacity to promote the functional mobility of residents are needed as well (e.g., education for nursing staff or environmental changes) [20]. Either type of mobility intervention tends to be quite complex and to comprise a variety of components [21,22,23].

For the development of such complex interventions, it is strongly recommended not only that the outcomes of the intervention be evaluated but also that the process of implementing the intervention be considered [24,25,26,27]. This is especially recommended since the benefit depends not only on the effectiveness of the intervention itself but also on its successful implementation in real-life settings [27]. Multiple factors can influence such implementation processes [28, 29] and need to be addressed by tailored implementation strategies [30].

To ensure the effective and sustainable implementation of mobility interventions, these influencing factors need to be considered and implementation strategies need to be systematically investigated. However, to date, such implementation aspects of mobility interventions have only marginally been investigated, and to our knowledge, a comprehensive and systematic overview of evidence is missing.

To close this research gap, we conducted a scoping review with the objective to identify and descriptively summarize the available evidence on implementation strategies and influencing factors for the implementation of interventions to promote and maintain the functional mobility of NH residents. Considering (A) direct interventions as well as (B) organizational capacity-building interventions we addressed the following two research questions:

  • What strategies for the implementation of (A) direct interventions and (B) organizational capacity-building interventions to promote and maintain the functional mobility of NH residents have been investigated?

  • What factors influence the implementation of (A) direct interventions and (B) organizational capacity-building interventions to promote and maintain the functional mobility of NH residents?

Methods

Scoping reviews are especially recommended to explore the extent of the available literature and to map and summarize the evidence in a given field [31]. Thus, to conduct this review, we followed the methodological guidance for the conduct of scoping reviews as described by the Joanna Briggs Institute [31, 32]. Accordingly, we used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)[33] for the reporting of the review (Supplementary Table S1). Furthermore, we developed an internal review protocol to guide the process.

Literature search

We developed two separate search strategies addressing the two different types of mobility interventions (A, B). For the development of the search strategies, we adapted the ‘Population, Concept of interest, Context (PCC)’ mnemonic [31] and clustered our search terms accordingly: population = nursing home (1); concept of interest = implementation strategies and influencing factors for the implementation (2); and context = interventions to promote and maintain the functional mobility (3). We developed a set of search terms for each PCC element, which we adapted after an initial explorative search. We combined the PCC elements into two search strategies. While we differentiated element 3 (context) with regard to the type of mobility intervention (A, B), elements 1 and 2 remained the same for both search strategies. Additionally, we used key publications to identify free search terms and indexing words. The search strategies were developed by two reviewers (TQ, CM) and were then reviewed and discussed within the project team (TQ, CM, MRM, JIB, MR) and with the Bundeszentrale für gesundheitliche Aufklärung (BZgA)(CR) based on the Peer Review of Electronic Search Strategies [34]. Searches were conducted in the following electronic databases: MEDLINE (via PubMed) and CINAHL (via EBSCO). The search strategy was first developed for MEDLINE (Supplementary Table S2) and then adjusted for CINAHL with RefHunter V.5.0 [35]. The searches were conducted in November 2020. Additionally, we performed backward and forward citation tracking via reference lists of the included studies.

Study selection

We defined the inclusion criteria based on the research aims and questions and clustered them according to the PCC mnemonic [36]. Additionally, we defined criteria for the type of evidence and language (Table 1).

Table 1 Inclusion criteria
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References identified through our literature search were imported into Covidence software [39] and automatically checked for duplicates. Titles and abstracts of the remaining references were independently screened against the inclusion criteria by two reviewers (TQ, CM). Divergent ratings were discussed between the two reviewers, and in case of no consensus, the respective references were discussed with selected coauthors (MRM, JIB, MR). For the full-text screening, we applied the same strategy. Covidence software [39] was used for both screening steps.

Data extraction and management

We adapted the Joanna Briggs Institute template for scoping reviews [36] for data extraction. According to the procedures described by the Joanna Briggs Institute [36], we developed the final data extraction template in an iterative process. This means that we validated and adjusted the initial template, while the first studies were extracted until all relevant data were represented with the template. Finally, the following data were extracted from all studies: study name, authors, year of publication, country, study aim, study design, methodological/ theoretical approach, methods, sites, study population, mobility intervention (incl. target population), implementation outcomes, evidence on 1) implementation strategies and 2) factors influencing implementation. Data extraction was performed by one reviewer (TQ) and then cross-checked by a second reviewer (CM).

Data analysis and synthesis

The identified implementation strategies are summarized descriptively.

To analyze the influencing factors of implementation in the included studies, we conducted a qualitative content analysis [40]. We derived the initial deductive categories from the Consolidated Framework for Implementation Research (CFIR) [29] (Supplementary Table 3). Using MAXQDA V. 2020.2.0 [41], the included studies were coded by one reviewer (TQ or CM), and each was cross-checked by the other reviewer. Both reviewers discussed divergent ratings, and recoding was undertaken if necessary.

Stakeholder conference

We presented the findings to and discussed them with CR (BZgA) and five stakeholders from different welfare organizations in long-term care to confirm and refine our interpretations. The stakeholders were managers and project managers, who were responsible for organizational development and quality improvement within their organizations on a regular basis.

Results

Through the electronic database searches, we identified a total of 2218 (A) and 1841 (B) records. After deduplication, we screened 1666 (A)/1453 (B) titles and abstracts for relevance, which resulted in the screening of 111 (A)/72 (B) full texts. Finally, we included 16 studies reported in 21 reports [42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62] in the review (Fig. 1).

Fig. 1
figure 1

PRISMA 2020 flow diagram for new systematic reviews, which included searches of databases, registers and other sources [63]. *Numbers for search strategy A (direct interventions) are presented in black/on the left side throughout the flow diagram. **Numbers for search strategy B (capacity-building interventions) are presented in red/on the right side throughout the flow diagram

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Study characteristics

Table 2 provides an overview of the included studies. The studies were from different countries: Canada (n = 3) [42, 43, 45, 46, 51], Australia (n = 3)[47, 49, 50], the Netherlands (n = 3) [57, 60, 61], the UK (n = 2) [52, 56, 58], the USA (n = 3) [44, 53, 59], and Germany (n = 2) [48, 62]. They were published between 2006 and 2020. A variety of designs were used within the studies and their sub-studies, including a qualitative design (n = 5)[43, 49, 50, 53, 59], mixed methods (n = 3) [56, 57, 61], process/scientific evaluation (n = 3) [46, 48, 60], case study (n = 2) [47, 58], quasi-experimental pilot study (n = 1) [51], cluster randomized trial (n = 2)[45, 62], quality improvement project (n = 1) [44], cohort study (n = 1) [52], and quantitative pre-post-design (n = 1) [42].

Table 2 Overview of the included studies
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Description of the implementation strategies

Seven studies [42, 44,45,46, 51, 57, 62] of the 16 included studies provided evidence on implementation strategies. Different implementation strategies such as staff education/trainings/information [42, 44, 55, 62], different types of reminders [45, 46, 51], audit and feedback interventions [44, 46, 51, 62], guiding coalitions [44, 62], assessment of environmental/influencing factors [44, 57], and development of individual implementation strategies [57] were described. All studies combined at least two different implementation strategies. Implementation outcomes such as fidelity [45, 57], sustainability [45], adherence [44], dose [57], context [57], satisfaction [57], complexity [57], adaptations [57], and intervention uptake [42, 51] were used to examine the effect or the feasibility of the implementation strategies or to evaluate the implementation.

Table 3 gives an overview of the studies that assessed implementation strategies and their results related to the implementation strategies.

Table 3 Overview of the implementation strategies identified within the included studies
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Factors influencing implementation

All 16 of the included studies described factors influencing the implementation of mobility interventions for NH residents. In total, we identified 32 of the 37 influencing factors of the CFIR (Table 4)[29]. The five most frequent influencing factors were available resources (n = 14)[43, 44, 46,47,48,49,50,51, 53, 56, 58,59,60, 62], access to knowledge and information (n = 12)[43, 44, 46,47,48, 53, 56, 58,59,60,61,62], patient needs and resources (n = 10)[43, 47,48,49,50, 52, 53, 56, 58, 59, 62], knowledge and beliefs about the intervention (n = 10)[43, 44, 46, 48, 49, 53, 56,57,58, 62] and compatibility (n = 9)[43, 48,49,50, 53, 58,59,60, 62].

Table 4 Overview of the influencing factors identified within each study
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Available resources, such as time [43, 44, 46, 47, 49, 53, 56, 60, 62] staff [43, 46, 48,49,50,51, 56, 58, 60, 62], environment [46, 49, 50, 56, 58, 62], (exercise) equipment [50, 53, 58, 59, 62], aids and trainings [53, 62], were described as the most frequent factors influencing implementation. In addition, access to knowledge and information related to sufficient information and training regarding the intervention [43, 47, 53, 56, 58, 59], transparency about the implementation project [43, 48, 58, 61], opportunity to attend trainings (e.g., shift arrangement, staff absence, vacation, lack of information) [56, 61, 62], different types [62] and multiple of training [46, 60], access for the whole team [61] and (enough) trained staff [58, 62] were mentioned as influencing factors. Influencing factors related to the residents (patient needs and resources) were motivation of the resident [43, 47, 48, 53, 62], resident compliance [49, 62], willingness to participate [43, 48, 53, 58], attitude and expectations toward the intervention and mobility [53, 58, 62], cognitive and physical abilities [43, 47,48,49,50, 53, 56, 58, 59, 62], health status (including pain and fatigue)[43, 49, 50, 52, 53, 58, 62] and social engagement [52]. Additionally, the persons present during the exercise (e.g., nurses, leaders, relatives)[47], the resident’s guidance and support [47, 53, 62], and responses to residents’ needs (e.g., giving time, simple commands, control, and verbal encouragement)[53] were reported. In relation to the residents, their relatives and relatives’ knowledge and expectations regarding the intervention and mobility [53, 59, 62], and their uncertainty [62], motivation [62], cooperation [47, 62] and involvement [47, 59, 62] were also mentioned as relevant factors. In addition, the knowledge and beliefs about the intervention of the individuals involved in the implementation were described frequently as factors that influenced implementation. In this regard, knowledge about the intervention and its benefits [43, 46, 49, 53, 57, 58, 62], expectations related to outcomes and workload [48, 53, 56, 58, 62], roles and task understanding [49], and attitudes toward the intervention [48, 56, 62] were reported. Another frequently mentioned influencing factor was the compatibility of the intervention with existing care/practice routines and workflows [58, 62], organizational structures [62] and organizational culture [48, 53], staff’s perceived risks [43, 49, 50, 53, 60, 62], resident rights [59] and other projects [62].

Discussion

In this scoping review, we identified 16 studies [43,44,45,46,47,48,49,50,51,52,53, 56,57,58,59,60,61,62] that provided evidence on the implementation of interventions to promote or maintain the functional mobility of NH residents. Most of these studies presented evidence regarding factors influencing such implementation processes [43,44,45,46,47,48,49,50,51,52,53, 56,57,58,59,60,61,62], but the scope and depth of evidence varied between the studies. Studies systematically covering a broad range of different implementation aspects were mostly missing and were most likely to be found among those few studies that provide evidence on implementation strategies [42, 44,45,46, 51, 57, 62]. However, even among these studies, only the research program on the sit-to-stand activity examined implementation aspects with a successively developed step-by-step approach and with a long-term perspective considering study results from the previous steps to develop tailored implementation strategies [42, 45, 46]. This may reflect the lack of systematic approaches to designing implementation research [67], which was also underlined by a scoping review by Yang et al. 2020 [68]. In their review, the authors included RCTs on the effectiveness and implementation of recreational therapy programs to enhance functional mobility. Even though they were able to derive some evidence on implementation issues, the included RCTs mainly focused on intervention effectiveness.

Overall, it can be stated that the implementation of mobility interventions for NH residents has thus far been insufficiently investigated. Nevertheless, this review brings together the evidence available to date on this topic and thus provides valuable indications for the successful implementation of such interventions.

Implementation strategies

Those studies that examined implementation strategies showed a range of different approaches. The study program of Slaughter et al. [42, 43, 45, 46, 51, 54, 55] referred to a simple direct mobility intervention and examined discrete implementation strategies [69], while the other studies examined either more complex organizational capacity building interventions[57, 62] or more complex implementation approaches [44, 57, 62].

Reminder systems, as systematically investigated by Slaughter et al. [45, 46], are common and listed in different taxonomies of implementation strategies (e.g. [69,70,71]). The findings that Slaughter et al. [45] reported have been supported by other studies. Cheung et al. [72] concluded from an overview of 35 systematic reviews that reminder systems are effective in improving healthcare professionals' behavior and that they are more likely to be effective if they are tailored to the respective care setting. In this regard, the literature describes very different types of reminders, ranging from very simple to highly complex formats [72]. Thus, the systematic approach described by Slaughter et al. [45, 46] to investigate different reminder systems meets these requirements.

Görres & Rothgang [62] suggested that that the combination of education sessions and accompanying implementation strategies was a successful strategy for the implementation of the national expert standard “Maintenance and promotion of mobility in care”. Generally, educational meetings are considered to be established in routine care and effective in improving professional practice [69, 73], but Forsetlund et al. [73] pointed out that "educational meetings alone are not likely to be effective for changing complex behaviours" (p. 1). Thus, the combination of educational sessions and additional implementation interventions as used by Görres & Rothgang [62] seems promising.

Often, not a single implementation strategy but rather multiple, more complex implementation strategies are used. For example, Powell et al. [69] understood their compilation of implementation strategies as a "list of discrete strategies that can serve as ‘building blocks’ for constructing multifaceted, multilevel implementation strategies" (p. 7). In line with this, Slaughter et al. [42, 43, 45, 51] also combined reminder systems with other strategies (e.g., audit-and-feedback intervention, informal walkabouts) and conclude this to be supportive for implementation success.

For the design of multifaceted, multilevel implementation strategies, it is recommended that they fit the respective implementation context [74, 75]. However, such tailoring of implementation strategies is particularly challenging [30]. In particular, the consideration of context-specific implementation determinants seems crucial for success [75, 76]. Accordingly, the approaches described in the studies by Kuk et al. [57] and Kazana & Pencak Murphy [44] are of interest, since both represent a comprehensive implementation approach focused on organizational development. In particular, the TIP-toolbox by Kuk et al. [57] represents a systematic approach for developing a tailored implementation strategy. The TIP-toolbox not only considers barriers and facilitators for the implementation but also represents a theory-driven and step-by-step approach that is guided by the implementation of change model [66]. This can be understood as a key success factor since theoretical framing is reasonable for the development and application of tailored implementation strategies [69, 77]. Additionally, Kazana & Pencak Murphy [44] considered barriers and facilitators within their approach.

In summary, the studies investigated a spectrum of promising implementation approaches. However, only the research program on the sit-to-stand activity showed a step-by-step and long-term approach.

Influencing factors

All of the included studies reported influencing factors of the implementation of mobility interventions for NH residents. These influencing factors relate to the process of implementing mobility interventions. In this respect, the findings of our scoping review indicate which facilitating and inhibiting factors need to be considered when implementing mobility interventions into real-life settings. However, based on the findings, no statements can be made regarding the impact and causal connections of the mobility interventions applied in the identified studies.

Altogether a broad range of influencing factors was identified, which included almost all influencing factors that the CFIR comprises. Available resources, access to knowledge and information, patient needs and resources, knowledge and beliefs about the intervention and compatibility were identified as the most frequently reported influencing factors. Reviews addressing the implementation of other interventions, such as complex interventions in general, fall prevention or guidelines in NHs, have identified similar influencing factors [78,79,80,81]. In particular, lack of time, staffing ratio, missing equipment and training have been described as barriers [78,79,80,81] to the implementation of various interventions in NHs, and they represent a vital challenge of the conditions in this care setting. Abilities, attitudes, expectations of residents and the influence of relatives have also been described as important influencing factors in other reviews [79,80,81]. Implementation strategies such as resident and involvement of the relatives, knowledge transfer, and tailoring of interventions can be used to address this kind of factor that influences implementation. The matching tool developed by Waltz et al. [75] could – for example – be used to specifically address known barriers with suitable implementation strategies.

Regarding the different types of interventions (direct (A) vs. organizational capacity-building (B) interventions), no major differences in the influencing factors could be identified. The five most important influencing factors were reported with somewhat equal frequency relative to both types of interventions (A and B). Different influencing factors of the CFIR inner setting domain and its networks and communication and culture constructs were more often identified as influencing factors for the capacity-building interventions than for the direct interventions. Conversely, more influencing factors related to the CFIR domain characteristics of the intervention were identified for the direct interventions.

Limitations

The scoping review had some limitations. The concept of organizational capacity-building interventions lacks an internationally established definition. Since the term “Verhältnisprävention” covers this concept for the German context, we built our search strategy B based on the definition of this term [82, 83]. However, an internationally accepted definition might have led to other aspects to be considered. Furthermore, we only included studies in English and German, and no librarian was involved in the development of the search strategies. However, the researchers involved had both subject-specific and methodological expertise in conducting reviews. Despite the limitations just described, we were able to generate valuable findings. Above all, the systematic approach based on proven standards [32] and the ongoing exchange within the research team contributed to this.

Conclusions

The results of the review provide an overview of the currently rather limited evidence on the implementation of interventions to promote and maintain the functional mobility of NH residents. In particular, there have been few studies examining implementation strategies. However, these studies provide some promising approaches that can serve as a starting point for further research. Studies that evaluate discrete implementation strategies for direct mobility intervention (e.g., the sit-to-stand activity) as well as studies that further develop multifaceted, multicomponent implementation approaches (e.g., the TIP-toolbox) with a focus on complex interventions that also include capacity-building components are recommended here. In contrast, many of the studies reported influencing factors of the implementation. According to our findings, the implementation of mobility interventions especially required sufficient resources, access to knowledge and information for all staff, and consideration of the needs and resources of residents and their relatives. These findings can be considered in practice and research for the development of tailored strategies for the implementation of mobility interventions. Furthermore, the identified indications of differences between (A) direct and (B) capacity-building interventions might be considered in the process of developing tailored implementation strategies. However, further research is needed on this topic.

Finally, it is important to emphasize that the impact of the review’s findings extends beyond intervention studies in nursing home settings alone, and therefore hold relevance and value for various types of research in nursing homes and other geriatric care settings. They can provide guidance and insights for researchers and practitioners exploring different aspects of nursing home and geriatric care, including e.g., practice and quality improvement initiatives, resident well-being, or policy development.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

BZgA:

Bundeszentrale für gesundheitliche Aufklärung

CFIR:

Consolidated Framework for Implementation Research

NH:

Nursing home

PCC mnemonic:

Population, Concept of interest, Context mnemonic

PRISMA-ScR:

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews

TIP-toolbox:

Translating Innovations into Practice-toolbox

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Acknowledgements

We thank the BZgA for funding this study [grant number Z2I33.6.2.2PI20]. We thank the stakeholders for critically discussing our findings, which helped us to reassure and refine our interpretations.

Funding

Open Access funding enabled and organized by Projekt DEAL. This study was funded by the Bundeszentrale für gesundheitliche Aufklärung (BZgA) [grant number Z2I33.6.2.2PI20].

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  1. Tina Quasdorf and Christina Manietta share first authorship.

Authors and Affiliations

  1. School of Health Science, Institute of Nursing, ZHAW Zürich University of Applied Science, Winterthur, Switzerland

    Tina Quasdorf

  2. Deutsches Zentrum für Neurodegenerative Erkrankungen e.V. (DZNE), Standort Witten, Witten, Germany

    Christina Manietta, Mike Rommerskirch-Manietta, Jana Isabelle Braunwarth & Martina Roes

  3. Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Germany

    Christina Manietta, Mike Rommerskirch-Manietta, Jana Isabelle Braunwarth & Martina Roes

  4. Bundeszentrale für gesundheitliche Aufklärung (BZgA), Köln, Germany

    Christin Roßmann

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Contributions

All authors meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Study concept and design: TQ, CM, MRM, JIB, CR, MR. Acquisition of data: TQ, CM. Analysis and interpretation of data: TQ, CM, MRM, JIB, CR, MR. Drafting of the manuscript: TQ, CM. Critical revision of the manuscript for important intellectual content: TQ, CM, MRM, JIB, CR, MR. Final approval of the version to be published: TQ, CM, MRM, JIB, CR, MR. Agreement to be accountable for all aspects of the work: TQ, CM, MRM, JIB, CR, MR.

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Correspondence to Tina Quasdorf.

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Quasdorf, T., Manietta, C., Rommerskirch-Manietta, M. et al. Implementation of interventions to maintain and promote the functional mobility of nursing home residents – a scoping review. BMC Geriatr 23, 600 (2023). https://doi.org/10.1186/s12877-023-04213-5

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BMC Geriatrics

ISSN: 1471-2318

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