Assessing the implementation of nurse practitioner-led huddles in long-term care using the Consolidated Framework for Implementation Research (CFIR)

Evidence strength and quality was rated consistently positively across sites, participants perceived the intervention as effective and believed that it would address staff needs. Huddles were regarded as an opportunity for staff to communicate more effectively with each other and with leadership. Participants noted that staff were able to discuss topics they may not have usually addressed with leadership due to time constraints or lack of comfort in approaching management. Staff described feeling heard in the huddles and were able to discuss topics which leadership. In the words of an NP, “[I] may not be able to do anything about it, but just recognizing that they have concerns” (01 NP) *Given the sample size, we do not provide further information on participants, such as their site, to prevent identification and preserve their anonymity. In addition, participants described having greater and timelier access to information. As a direct care provider (DCP) noted, they accessed information they would not have “on a good day” (07 DCP). Huddles also provided an opportunity for interdisciplinary problem solving amongst staff regarding both staff wellbeing and resident care, as a manager explained:

“Just being able to communicate as a multi-disciplinary team and take down those silos – the housekeeping, the nursing department, the different departments all kind of having struggles over the same things.” (19 Management)

Huddles also provided the opportunity for connection between disciplines. Staff described the intervention as effective in team building. An NP said that huddles promoted “team comradery … and support for the teams within” (09 NP). One DCP noted that huddles allowed participating individuals to realize that they were all members of the same interdisciplinary team (07 DCP). Furthermore, staff believed their wellbeing and morale was improved. A DCP explained that “when staff know each other on a personal level and they understand what struggles people are going through, they’re more willing to understand and support each other” (14 DCP).

Developing solutions during the huddles also gave staff some peace of mind. One DCP reflected that they were “not just sitting and being angry and upset and tired. We’re actually trying to improve something, change something” (20 DCP). Staff worked with the NP to create action and follow-up plans and develop opportunities for improvement within the home. By improving communication, connection, and problem-solving, participants agreed that the intervention’s strengths were beneficial to the home and effective in ultimately supporting quality of care of care provided. One DCP recognized that “ultimately, what [huddles] benefit is the care that we provide at the frontline” (14 DCP).

The needs and resources of staff were rated as strongly negative across both sites; capacity to address staff needs was lacking. Prior to implementation and emerging from the second wave of the COVID-19 pandemic, participants described care providers as experiencing an “overall burnout” (01 NP). The LTC homes struggled to maintain adequate staffing, one DCP noting they were “often working short or doing more than one role at the same time” (06 DCP). Management reported spending much of their time finding available staff, and one site ultimately hired agency staff, a solution that managers described as a last resort. Chronic short staffing posed a challenge to huddle implementation as staff found it difficult to participate and respond to care needs simultaneously:

“Staff are pulled from the time that they are supposed to be finishing their charting, answering the call bell, putting the residents on the toilet – and they are taken from that time. And they’re sitting there, they’re really worried – they’re not even fully focused because they need to go back and finish their job.” (16 DCP)

The possibility of having just one additional person working on the unit was viewed by participants as potentially beneficial in addressing this concern. They perceived that this would allow staff to focus on the huddles, since the extra support would make up any time taken away from direct care. One DCP explained, “in a perfect world, you replace me [on the floor] and then we can have a huddle, no problem” (17 DCP). In Site 1, such a novel role was described as a formalized position of resident coordinator, a role that would ensure continuity and communication surrounding the huddles. In Site 2, rather than creating a new role, they suggested introducing an additional staff member “to watch the call bell or to actually pick up what [DCPs] are supposed to be completing” (16 DCP). However, difficulty filling these positions in both sites meant staff were not provided with this resource. Because of this, staff were not always able to participate in the huddles. NPs worked to accommodate staff’s schedules, to find a more available time of day, such as during shift handover.

However, participants believed that due to conflicting responsibilities this intervention had become a lower priority for leadership, reducing their participation. Management expressed difficulties in “getting away from their desks … We can try as hard as we like but it’s not easy” (02 Management). They described specific competing responsibilities, including visits from the Ministry of Long-Term Care, resolving resident critical incidences, and addressing the staffing crisis. One manager stated, “the last two days I’ve done nothing but scheduling and really my heart’s out on the units” (19 Management). Leadership agreed that they would like to take on a role in supporting the huddles, however, as one manager explained, “I just haven’t been able to attend them as much as I wanted to or be as much of a support as I hoped to be … We were just running on quicksand and just trying from this end to help as much as we can” (19 Management). Like staff, management were described as experiencing burnout. As one NP described, “managers are distressed and unless you can really support the managers and help them move forward, how can they support the staff?” (01 NP). Managers agreed that this was exacerbated by the COVID-19 pandemic. One manager stated it became “incredibly challenging to manage anything during this pandemic beyond everyday operations” (10 Management).

All participants spoke of the value of leadership involvement to ensure consistent and sustainable huddles. Staff voiced the importance of leaders as role models in “organizing and setting aside the time” (13 Non-direct care provider [NDCP]) to huddle, and the authority of top-level managers to say, “[huddles] are what we’re doing. And we’re sticking with it.” (04 Management). Participants suggested that optimal leadership engagement would entail attendance at huddles, particularly when discussing topics pertaining to their roles and responsibilities. For instance, a DCP noted management’s presence would be important “if management is part of solving the problem, either dealing with the family or resident or something drastic that has been happening on the unit” (20 DCP). The NP and DCPs described difficulties in following through to resolve particular issues raised during the huddle when it exceeded their role capacity. One DCP noted topics such as “questions about staffing or … stuff that’s out of [a DCP’s] control” (22 DCP). One NP described the additional workload they took on trying to “mitigate some of [communication issues] amongst the home and the staff” (09 NP) that are more readily resolved with the managers’ participation in huddles.

Participants perceived an leadership engagement as a priority. One DCP stated, “I don’t know that they recognize or understand how important their actual participation in it is too” (14 DCP). NPs and staff emphasized the importance for leadership presence at huddles. One NP explained, “I think the staff really want to know that their concerns, or even the good things that they do are heard by the people that lead them” (01 NP). This would allow management to interact and engage with staff. The other NP agreed, stating managers could “have their ear to the ground so to speak … Then they’re there on the frontlines, they’re seeing what the staff are seeing, they’re hearing their concerns directly.” (09 NP). They perceived benefits beyond improving staff morale, participants suggested leadership engagement would contribute to staff participation in the intervention. One DCP said, “I think to get the buy-in of the majority of the staff, we’re going to have to see senior management be willing to be a part of these huddles” (12 DCP). However, some participants noted that when management were able to attend, they observed a shift in the dynamic of communication, in that “people were not as open” or “free to talk” (07 DCP). It was suggested that this would be resolved when “[huddles] become more like a routine thing” (20 DCP), thus allowing more time for staff to acclimate to leadership presence and continue to engage effectively in the huddles.

The relative priority of the intervention was perceived as low amongst all participants, thus strongly, negatively influencing implementation at both sites. Participants acknowledged the intervention’s importance, however, agreed that with limited capacity at both sites resident care was prioritized:

“Everyone you pull someone away from the floor, you’re actually taking them from the residents, which means residents receive less support. There’s always that delicate balance of trying to ensure that we provide as much care as humanly possible to the residents to ensure their overall support and safety but also ensure that teams are supported.” (09 NP).

One manager described care staff as “struggling to meet the basic care needs … which kind of stops you in your tracks from what you want to [implement]” (19 Management). Participants identified the staffing crisis as the cause of this difficulty. Both sites described their teams as “chronically short-staffed” (18 Management) and noted that this would remain a challenge for all LTC homes, particularly emerging from the COVID-19 pandemic. One manager stated, “everyone’s in shortage. People are walking away from long-term care” (04 Management). As a result, increases in workload meant it was “difficult to actually allocate that time” to the intervention, one manager emphasized that “everyone’s role is so so stretched” (11 Management). Participants described staff experiencing greater stress due to time spent in the huddles. One manager noted, “even if it’s just 15 minutes, it’s enough to derail their day” (10 Management). Participants described it as difficult to identify willing facilitators for the huddles, as “nobody really has the capacity right now” (11 Management).

Over time, however, participants perceived that the intervention increased in priority, suggesting that the length of the implementation period may be important for determining its success. Despite the time commitment, huddles were perceived to ultimately improve staff’s capacity for resident care as huddles provided solutions to daily challenges. Participants agreed that a decrease in huddle frequency to once or twice weekly would allow for more effective changes to be enacted, as, unlike acute care where huddles originated, the LTC home setting does not change rapidly day-to-day: “So we actually have things that move and change and then … if we’re having a problem, get together and talk about it” (20 DCP).

As the initial huddle facilitators, both NPs were passionate and committed to the intervention. One manager explained that the NP’s “level of engagement and enthusiasm and passion for [their] work contributed to good outcomes” (10 Management). The multifaceted role of the NP was credited with success as facilitator, as they leveraged their skills as clinicians and leaders to build staff’s clinical skill, but also provide emotional support:

“That’s part of the [NP] role, is leadership … We’re able to talk about clinical practice, we’re able to talk about de-stressing and debriefing which is sort of our counselling role … we have that connection, we go and talk to the families, we assess the resident, we can build skills.” (01 NP).

Participants believed it was beneficial that the initial champions driving the intervention were third parties with good knowledge of residents. One NP suggested, “I think they were more comfortable sharing and talking with me and sharing their concerns” (09 NP). With regards to clinical issues, one manager noted, “the NP gives confidence that [staff] have a well-informed, well-educated person” (02 Management). Additionally, the NPs’ position of authority in both sites meant they “actually get things done” (21 DCP) and could persevere in resolving issues involving interdisciplinary collaboration and management involvement. Both NPs noted the challenges associated with this role; additional time to ensure effective implementation, including encouraging participation, engagement, and sustainability, while also communicating with leadership and facilitating remote huddles when required all increased their workload.

NPs encouraged unit leaders to sustain the huddles, “I did work hard to build that capacity and that independence so that they could do these huddles outside of just having me present” (09 NP) noted one NP. However, this transition did not occur “smoothly … because they were used to the nurse practitioner” (04 NDCP) and the staff were reluctant to assume the role of champion. One participant suggested, “Maybe it’s because we had such a hard year and everybody’s tired and overworked. So, they weren’t really willing to jump in and fill in the position” (20 DCP). Unit leaders agreed that they “don’t want that responsibility because [they] have enough responsibilities” (07 DCP). In comparison to the NP role, staff felt unequipped. One participant described their hesitancy in dealing with “all those questions and having to come up with ideas or brainstorming or going to find someone to answer the questions” (07 DCP). Leaders on the unit expressed concern that facilitating and addressing the concerns raised during the huddles were beyond their scope of knowledge and power. Staff suggested that a more formal process with ongoing support might help them prepare for this transition. This construct was revealed to be significant in implementation sustainability, as participants agreed it was unclear who would continue leading and sustaining the huddles, without the NP as champion.