Effect of the HIRAID (Registered) Aged Care Nursing Framework on the Quality and Safety of Residential Aged Care

Name: HIRAID (Registered) Aged Care Step-Wedge Clustered Randomised Controlled Trial Materials: The intervention will involve the delivery of HIRAID (Registered) Aged Care practice, education and training materials to aged care nurses. HIRAID (Registered) Aged Care is a nine-component framework (History including Infection Risk, Red Flags, Assessment, Intervention, Diagnostics, Reassessment, Communication and Plan) adapted from the HIRAID (Registered) nursing framework, which was originally developed for, and implemented in, emergency departments. History: Collect residents' health history, identify immediate problem/s, understand resident's values, preferences, goals of care. Assess potential for Infection Risk. Red Flags: Historical and physiological indicators to recognise serious illness and notify GP ASAP. Consider referral to in-reach services. Assessment: Physical examination beginning with primary survey, the focused assessment and vital signs. Intervention: Should be evidence-based and prioritised based on assessment. Diagnostics: To gain clinical picture and inform treatment decisions. Reassessment: Evaluate care and monitor patient progress. Maintain a structured approach and repeat at appropriate intervals. Communication and Plan: With residents, families, clinicians. Use structured approach for clinical handover, with graded assertiveness to escalate if needed. Accurate and comprehensive clinical documentation. Registered nurses will be trained and certified in the HIRAID (Registered) Aged Care, which will be implemented into the RACFs standard model of practice and care. Materials delivered may vary slightly between facilities and this will be informed by a comprehensive implementation strategy to determine what material modalities will best suit each facility (this is further details in 'Tailoring and personalisation'). Overall, HIRAID (Registered) Aged Care materials will take a combination of the following forms: an informational booklet, a training workbook to be completed in a face-to-face workshop, a learning module (which will transfer the contents of the workshop into a self-directed module with both online and material components), paper templates, electronic templates integrated into the facilities’ electronic medical system, posters and reference cards attached to work lanyards. Procedures: Training will be implemented in two stages and will occur consecutively within the intervention period. The first stage will involve a four-hour interactive Provider Workshop, where nurses are provided with all education materials (i.e. booklet, workbook, documentation templates) and learn how to apply the framework to their practice. The second stage will involve the delivery of a four-hour practical Facilitator Workshop ('train-the-trainer') whereby clinical nurse educators/consultants (CNE, CNC) are trained to implement the HIRAID (Registered) Aged Care framework, as well as to deliver this training and supervise its successful uptake for the nursing staff in their facilities. This process ensures the long-term delivery of the intervention in the facility even with the turnover of nursing staff. All training will be facilitated by research implementation nurses, who correspond directly with the research team. These implementation nurses will also be integral for overseeing the onsite implementation fidelity of the intervention (e.g. whether training was administered to the correct standard and whether all supporting materials like posters, booklets and cards have been distributed). Once the training is completed, documentation templates (paper and, where relevant, electronic) will be integrated into the facility. For example, if paper documentation templates were previously used, these would be replaced with paper based HRIAID (Registered) Aged Care templates. If the facility used an electronic documentation system, the HIRAID (Registered) Aged Care template will be added in an appropriate format into this system. Nurses will be able to refresh their learning of the framework through both practice and through online learning resources, environmental cues (e.g. reference cards, posters) and behavioural reinforcement strategies (e.g. positive reinforcement from CNEs, documentation auditing, simulation training). Who will deliver: The first stage of training delivery (to CNE/CNCs) will be delivered by experienced members of the research team. Primarily, several members of the research team have been involved in the development and implementation of the original HIRAID (Registered) intervention in EDs. These members were also involved in the tailoring of the implementation strategy, educational materials and workshops for various EDs and are all registered nurses with extensive experience in the field. The CNE/CNCs will then be responsible for delivering the HIRAID (Registered) Aged Care training to nurses in their respective facilities. This will be performed in collaboration of the research implementation nurses (who are members of the research team and also act as onsite liaisons for each participating facility). Suitable CNE/CNCs will be identified for each of the facilities by the AI representative for each RACF. Staff in these positions are senior registered nurses who already work at the facility and who hold established responsibilities for managing the facility’s nursing workforce. Research implementation nurses will be specifically hired for purpose of overseeing the implementation of the intervention. These staff are also required to be registered nurses, have over at least 10 years of experience in practice and meet other criteria that will be established during the hiring process. Mode of delivery: As mentioned above, this intervention will employ are several modes of to facilitate framework retention and integration. The training will be provided in a combination of a face-to-face workshop, online correspondence and supported with both physical and online learning resources. Training for CNC/CNEs will be slightly more comprehensive, as they will also be required to deliver and supervise the training in general nursing staff. Training for the general nursing staff will generally take the form of a one-day face-to-face workshop and the continued delivery of physical and e-learning materials throughout the intervention to ensure successful uptake. Frequency and duration of delivery: The four-hour Provider Workshop will be delivered at least once at the commencement of the intervention period for each participating facility, and repeated on a needs basis to ensure at least 80% of employed RNs complete the training. Similarly, the four-hour Facilitator Workshop for CNE/CNCs will also be delivered once at the commencement of the intervention period. For both CNE/CNCs and the general nursing workforce, this is where most of the training in HIRAID (Registered) Aged Care will be imparted. Subsequent methods of reinforcement, such as individual training, completion of the learning module, documentation audits, environmental cues, simulation training sessions may all be implemented over a 6-month period depending on the facility. In particular, individual training and the one-time completion of the learning module will be a mandatory requirement for all new RNs employed to the facility and will be provided during their orientation. The frequency of these strategies will be informed by the implementation strategy developed for each facility prior to introducing the framework, as well as through regular (monthly) review of implementation fidelity with research implementation nurses. Location: All face-to-face training will be carried out onsite at each participating facility. A room to conduct the training will be arranged with each facility ahead of time and then visited and prepared by whoever is conducting the session. Additionally, the whole facility will then be involved in the intervention through the introduction of documentation templates and environmental cues. Finally, the e-learning aspect of the training will be made available online on a predetermined server managed by the research team. Tailoring and personalisation: The HIRAID (Registered) Aged Care framework will not be adapted for specific facilities, groups or individuals. However, the modes and frequency of delivery may vary based of facility characteristics, resident case-mix, staff demographics, infrastructure and other external factors. Prior to introducing the intervention, an implementation strategy will be developed for each facility. This strategy will be informed by a combination of nursing staff surveys and behavioural analytics obtained during the baseline data collection process. These surveys will help us identify the likely facilitators and barriers to the intervention and plan for potential solutions and modifications to how the intervention will be executed. For example, while some facilities may use electronic systems for recording resident health data, others may still rely on paper records. Therefore, documentation templated for HIRAID (Registered) Aged Care will need to be appropriately adapted to suit the recording systems used. Implementation fidelity: Fidelity of the intervention will be assessed by onsite research implementation nurses. A documentation template and log to record the implementation strategies that have been employed will be used to consistently document the intervention across all participating facilities. These documents will be collated and presented at regular team meetings with the research team, where we can assess the aspects in which the intervention can be improved.