A Systematic Review of Interventions to Change Staff Care Practices in Order to Improve Resident Outcomes in Nursing Homes

This systematic review examines the effectiveness of interventions to change staff care practices in nursing homes to improve resident outcomes. The review identifies barriers to implementation and facilitators of change. The study concludes that multidimensional interventions are needed to improve staff behavior and enhance the quality of care.

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A Systematic Review of Interventions to Change Staff Care Practices in Order to
Improve Resident Outcomes in Nursing Homes
Introduction:
It has been found that different studies have been introduced in order to provide
adequate evidence for the effectiveness of good practice to improve the prolong residential
care for the older people in the nursing homes, residential aged care home and long-term care
homes. However, in the research and practice unconscionable gap has been detected. After
the promotion of patient centred care the culture of changing effort has been spread widely in
the nursing homes of America. Still, it is unclear that whether the efforts in implementation
could bring changes within the staffs and the clinical practice. The effectiveness of practice
changes regarding the service quality and residential health outcomes are not clear as well. In
this regards some effective barriers in the way of implementation of good practice have been
recognized, for example, lack of innovation, high cost, lack of education of the staffs,
resistance in leadership and high rate of employee turnover. In addition lack of evidence
regarding the way of changing the behaviour of the health care staffs and changing the
culture of organization has contributed in the development of barriers in an effective manner.
However, implementation has been considered as one of the most important element to
bridge the lag between the practice and improved health service. Thus, it is important to
introduce further study in order to identify the proper way of implementing changes in the
clinical practice and behaviour of the staffs to improve the health outcomes as it was
identified by the previous systemic reviews that such interventions could help to achieve
successful outcomes (Low et al., 2015).

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PICO question:
Do the health care staffs with changed behaviour (P) using good practice that helps to
change behaviour (I) as compare to practice that is not associated with changed behaviour (C)
improve the long term residential care (O) within 6 months (T)?
PICO Table:
Population (P): Health care staffs with changed behaviour.
Intervention (I): Change the behaviour of the health care staffs and organizational culture and
introduce good practice in the health care.
Comparison (C): Practice that is not associated with changed behaviour of health care staffs.
Outcomes (O): Improved long term care and positive residential health outcomes in the
residential care of older people or nursing homes.
Time (T): 6 months.
Literature review:
Various studies have ensured that introducing good practice could help to improve the
residential long term care and help to achieve desired health outcomes. However, several
barriers have been found that restrict the changes in the clinical practice and create barriers in
the way of implementation of good practice. However, it has been found that implementation
of good practice could play a vital role in order to close the gap within the practice. Previous
literatures have examined the effectiveness of significant interventions in order to enhance
the residential health outcomes. For example, the previous researches have indicated that
intervention such as training of the health care staffs regarding the management of dementia
and psychological and behavioural effect has helped to improve the service provided to such

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patients. Such studies have focused on the efficiency of the interventions however, they did
not identify the interventions that lead to the changing practice in the health care. Thus, the
systemic review provided by Low et al., (2015) aimed to find out the interventions that could
help to change the behaviour and practice of the nursing staffs. The researchers have focused
on three main objectives such as to recognize and elaborate the studies systematically that
have examined the effectiveness of interventions to change the practice of health acre staffs
in order to improve residential health outcomes, to find out the elements of the strategies that
have contributed effectively to the successful approaches of staff practice in the health care
centres and to recognize the facilitators and barriers of the approach of change staff practice.
In order to conduct the systematic review the researchers have used effective
methodology and the method was chosen with the consultation of the librarian of an
information service university. It has helped to process the relevant previous studies in an
effective manner. The researchers have used effective databases such as MEDLINE,
CINAHL, PubMed and PsycINFO. English language and date from 1990 to 2013 has been
used. Search terms included nursing home, residential care, long-term, implementation,
organizational change, professional development and others have used to find out the related
literatures from the selected databases. The inclusion criteria includes studies that are
conducted in the residential care and nursing home, study that have used randomised control
trial or quasi experimental trial, studies that have used 3 or more sites, studies that have
aimed to change the practice of health care staffs and the studies included outcomes such as
change in the behaviour of the health care staffs, improved clinical and health outcomes and
satisfaction residential care. The researchers have screened the previous literatures and
identified the full text articles that have fulfilled the inclusion criteria and reviewed them to
derive the conclusion of the systematic review. Data has been collected regarding the
facilitators and barriers, different theoretical explanations of changed behaviour and some

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program logic models. Data was analysed and results were represented in tabular form. Risk
of bias has been eliminated by using the Cochrane Risk of Bias for EPOC reviews tool that
helps to identify the bias in performance, selection, reporting, detection and others (Low et
al., 2015).
The researchers have identified 7572 articles from which 211 articles were obtained
that contained full text. Among the full text articles only 77 articles have been found that
have fulfilled the inclusion criteria. In addition 2 articles were identified through the hand
searching reference. Therefore total 79 articles were selected including unique research in
order to obtain the desired result. 3 studies have examined the effectiveness of interventions
related to the staffs of oral residential care. 2 studies have inquired similar groups and
represented identical result as well. One study has provided information regarding the
training and using tooth brush as the interventions in order to improve the residential oral
care. However, none of them have identified the association of behaviour change with the
interventions, but reported the enhancement in the oral health. 2 studies have been selected
that have identified the impact of different interventions on the infection control and hygiene
factors. Intervention includes training associated with additional strategies. Both the studies
have reported regarding the improvement in the behaviour of the staffs related to hygiene
maintenance and infection control and positive changes in the health care staffs has led to the
consequence of improved health outcomes such as reduction in hospitalization, infection,
respiratory problems and other health issues (Low et al., 2015).
2 studies have been found that have focused on nutrition. Both of the studies have
supported the education and training program in order to introduce change in the behaviour of
the staffs and improvement in the indicators of nutrients as well. Pneumonia acquired from
the nursing home has been chosen by 2 studies as the field of experiment. The studies have
identified nurse training program and vaccination of the staffs as the interventions. However,

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difference in the outcomes has not been found. Depression related studies have been chosen
by the researchers for the systematic review. The studies have indicated training as the
intervention but association with staff outcomes has not been identified in the studies. 7
studies have been chosen that have provided information regarding the proper medication. It
has been found that providing education to the health care staffs could reduce the medication
error and improve the patient outcomes. Other interventions included feedback process,
meetings within the health care team and audit. However, the studies did not measure the
effect of the interventions on the behaviour of the staffs. Behaviour management and
psychological symptoms during dementia have been studied by 6 studies. Interventions
provided by the study include training, mentoring, using reminders and providing support.
However, only 2 studies have indicated the relation of interventions with change in behaviour
of the staffs. 11 studies related to fall prevention were also included that, among which only 5
studies have indicated impact of interventions on the staff’s behaviour (Low et al., 2015).
9 studies have been introduced to inquire the effectiveness of interventions in order to
enhance the care quality. One study has been identified the association of staff behaviour
with interventions and indicated the effectiveness of the interventions in order to improve the
health service and achieve expected health outcomes. Philosophy of care has been considered
in 10 studies and only 7 studies indicated change in the behaviour of the staffs but with least
improvement. Other domains in the clinical practice have shown positive outcomes. In
addition 3 studies have been introduced associated with program logic. The studies have
shown that the changes in the staff practice have not evaluated properly and only several
aspects were evaluated. The evidences did not provide strong logical link between
interventions and staff behaviour. 3 studies have indicated that implementing program for the
clinicians could be helpful to improve the behaviour of the staffs and introduce good practice.
Some studies have helped to find out the barriers such as absenteeism, high employee

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turnover, excessive work pressure, lack of communication, lack of funding and lack of
education. The care service provided by the staffs, needs of the residents and attitudes of their
families could act as the facilitators to introduce good practice and change the behaviour of
the staffs to enhance the quality of service. With such result the researchers have concluded
that adequate contemplating programs are needed to improve the behaviour of the health care
staffs and multidimensional interventions are needed. In addition further studies need to be
introduced to evaluate sustaining behaviour of the clinical staffs (Low et al., 2015).
Analysis of the quality of the literature:
In order to review the evidence and quality of the systematic review the CASP
checklist has been used for critical appraisal. The tool is effective as it helps to evaluate the
quality of systematic review through relevant questions that could help to identify the level of
evidence, quality of result and level of generalizability of the findings in order to evaluate the
overall quality of the paper (casp-uk.net, 2018).
CASP checklist for systematic review:
CASP checklist Comments for the study provided by Low et
al., (2015)
1. Did the review address a clearly focused
question?
Yes, the review has addressed clear question that
is whether the interventions related to good
practice could change the behaviour of the health
staffs.
2. Did the authors look for the right type of
papers?
Yes, the researchers have identified 79 relevant
papers.
3. Do you think all the important, relevant studies
were included?
Yes, relevant studies such as studies of oral
health, dementia, depression, fall prevention,

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medication, nutrition, philosophy of care,
infection control and program logic have been
included.
4. Did the review’s authors do enough to assess
quality of the included studies?
Yes, enough assessment of the quality of the
literatures has been done, for example,
assessment for meeting inclusion criteria and risk
of biasness has been done appropriately.
5. If the results of the review have been
combined, was it reasonable to do so?
Yes, the results of different studies have been
combined to elaborate a single factor and it was
reasonable as it helps to derive the result from
different studies based on similar group that have
provided identical findings.
6. What are the overall results of the review? The overall result have indicated that adequate
contemplating programs are required to improve
the behaviour of the health care staffs and
multidimensional interventions are needed to
enhance the quality of care and achieve positive
health outcomes in residential care.
7. How precise are the results? The results were précised enough and the tabular
form of findings has helped to understand the
result in a better manner.
8. Can the results be applied to the local
population?
The study was developed by focusing American
population. However, as the study based on the
population of developed country thus, it can be
said that the findings could be applied on the
population of other developed countries such as
Australia.

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9. Were all important outcomes considered? Yes, the systematic review has considered all
important and relevant outcomes regarding the
interventions and their effect on the behaviour of
the health care staffs. However, most of the
interventions were related to training and
education. Therefore, other interventions could
be addressed in order to strengthen the review.
10. Are the benefits worth the harms and costs? Yes, the benefits of the systematic review is
worth the harm and cost, because the
interventions provided by the study such as
training and education program could help to
improve the service of the health care staffs and
minimize the risk of harm. However, the findings
may be affected due to high cost.
Conclusion:
From the above discussion it can be said that, effective interventions need to apply in
order to introduce good practice in the residential care or hospital settings. It is important to
introduce good practice as it helps the nursing staffs to change their behaviour and adapt
healthy behaviour and help the hospitals and residential care home to change culture in an
effective manner. Such changes could help to improve the care service and achieve positive
health outcomes. However, some studies have indicated that there is no relation between
good practice and changing behaviour, but most of the studies included in the systematic
review have indicated association of good practice and changing behaviour. Thus, further
study is required to elaborate the fact in an effective manner,

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References:
casp-uk.net (2018). Retrieved from https://casp-uk.net/wp-content/uploads/2018/01/CASP-
Systematic-Review-Checklist.pdf
Low, L. F., Fletcher, J., Goodenough, B., Jeon, Y. H., Etherton-Beer, C., MacAndrew, M., &
Beattie, E. (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.

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