The DIMPLE study - De-IMPLEmentation of low-value care in home care nursing

BACKGROUND Low-value care is a waste of resources and caregivers’ time – and may cause harm to patients. Examples of low-value care mentioned by home care (HC) nurses are ‘performing daily full body wash and standard use of water and soap’ and ‘daily bandaging of legs and putting on compression stockings’. Sustainable de-implementation of low-value nursing care (LVNC) is difficult as it often requires giving up routines. AIM The overall aim of this action research proposal is to de-implement LVNC interventions in HC, using a tailored strategy according to the phases of the Choosing Wisely De-Implementation Framework (CWDIF). STUDY POPULATION HC nurses of at least 12 teams of three HC organizations. METHODS The study consists of three workstreams (WS). WS 1: SELECTION OF TOPICS AND POTENTIAL BARRIERS AND FACILITATORS RQ1a: What are potential topics of LVNC in HC (CWDICF phases 0 and 1)? We will survey nurses and the management of the participating HC nursing teams based on the Dutch list of 66 low-value nursing interventions and guideline recommendations for de-implementation LVNC. Based on the results we prioritize a list of LVNC interventions for de-implementation. RQ1b: What are the potential barriers and facilitators for de-implementation LVNC in HC by nurses’ (CWDIF phase 2)? Focus group interviews with nurses and management as well as individual semi-structured interviews with patients/clients will be performed, based on the Theoretical Domains Framework and the Integrated checklist of determinants of practice (TICD Checklist). Based on the interview results we will survey the prevalences and importance of the identified barriers and facilitators. WS 2: DEVELOPMENT OF THE TAILORED DE-IMPLEMENTATION STRATEGY RQ 2: What is the content of a tailored de-implementation strategy and the appropriate method of delivery and operationalization of the different elements of the strategy (CWDICF phase 2)? The tailored de-implementation strategy will be developed in six steps: 1) Thoroughly analysing de-implementation factors; 2) Linking de-implementation factors to theoretical constructs; 3) Considering useful theories and associated strategies; 4) Inventorying evidence for de-implementation strategies; 5) Selecting core strategies; 6) Arriving at a practical plan for de-implementation. Steps 5 and 6 in collaboration with patients and carers, nurses and management during focussed development sessions. This will ensure appropriate strategies and tailoring to the context. To allow the HC nursing teams to work with this de-implementation strategy (toolkit) during the study and afterwards, we will need to train implementation coaches. WS 3: ASSESSMENT OF THE TAILORED DE-IMPLEMENTATION STRATEGY RQ 3.1: Will application of the tailored de-implementation strategy reduce the use of LVNC interventions in HC (CWDICF phase 3)? *Design: The process of de-implementation of LVNC and its adherence will be studied in a prospective controlled before-after. - Intervention HC nursing teams; these teams will de-implement LVNC. - Control HC nursing teams; only data on the frequency of LVNC will be collected. *Setting: The study will be performed in three HC organizations located in the central (region Utrecht) and southwest (Rotterdam) regions of the Netherlands. In both the intervention group and the control group, twelve HC teams will participate. *Intervention: This consists of de-implementation of the selected LVNC interventions in HC using elements of the tailored de-implementation strategy (=toolkit) (see WS 2). The HC nursing teams will be responsible for de-implementation of their selected (at least one interventions) LVNC interventions. This will be an iterative-cyclical process consisting of three steps: a) defining target goals for de-implementation of the selected LVNC interventions; b) planning and acting by using the tailored de-implementation strategy; c) evaluating by measuring their target goals. *Outcome measures: *Primary: - Overall reduction of low-value home care nursing interventions. * Secondary: - Adherence to de-implementation strategies for the selected LVNC interventions. - Reduction of the frequencies of the separate LVNC interventions. RQ 3.2 What are the experiences of HC nurses with the de-implementation strategies? The process evaluation will give us insight in elements of the tailored strategy that are less feasible and must be adjusted for further implementation. Feasibility will be measured with the 23-item Normalisation MeAsure Development questionnaire (NoMAD). Further, nurses and implementation coaches will be interviewed to learn their perceptions of the study effects on local practice and the effects of the de-implementation strategy.