Process-evaluation alongside a cluster-randomized trial examining the effectiveness of the ‘SELF-program’ on nurses’ activity encouragement behavior

Background: The SELF-program is an interactive, tailored and theory-based training program that aims to improve nurses' activity encouragement behavior and indirectly to optimize nursing home residents' self-reliance in activities of daily living. The aim of this process-evaluation study was to evaluate the implementation, mechanisms of impact and contextual factors influencing the implementation and outcomes of the SELF-program. Methods: A process-evaluation with a mixed-methods design was conducted alongside a two-arm (SELF-program vs. care as usual) cluster randomized trial of nine months, examining the effectiveness of the program in Dutch nursing home care. Nurses from various qualification levels - registered and non-registered - were eligible to participate. Guided by the Medical Research Council framework, data on implementation parameters, mechanisms of impact and contextual factors were collected using checklists, evaluation forms, (attendance) logbooks, questionnaires and focus-group interviews among nurses and trainers. Quantitative data was analysed using mixed linear regression analyses, qualitative data using a deductive coding approach. Results: Twenty-eight nursing home wards - fourteen in each condition - from three care organizations across the Netherlands were included in the trial. Nurses were highly satisfied with the program and particularly valued its interactive content and team approach. The program was implemented with high fidelity, with 90% of all sessions completed and attendance rates averaging 60%. Attendance varied between organizations and declined over time. Improvements were observed in nurses' attitudes, perceived social influence, self-efficacy beliefs and intentions towards performing activity encouragement behavior, of which most were statistically significant, corresponding with small to medium effect sizes. These results were endorsed by data derived from focus-group interviews with trainers and nurses. Still, time constraints, staffing shortages and lack of motivation were put forwards as factors leading some nurses to still take over tasks. The presence of organizational policy regarding activity encouragement behavior, family member support, motivation of nurses, involving other disciplines and the interactive approach facilitated program implementation and outcomes. Contextual barriers to program implementation and outcomes included staffing shortages, low program attendance, time constraints, lack of manager support, and delivery of the program during the COVID-19 pandemic. Conclusions: Overall, the SELF-program was well received and implemented, with favourable improvements in mechanisms known to impact nurses' activity encouragement behavior. The program and its implementation could benefit from minor adjustments, as well as an improved attendance. Considering the results of this thorough process-evaluation as well as the positive results of the program on nurses' activity encouragement behavior, a widespread implementation is recommended.