Table 2 Ratings assigned to CFIR construct by Site

I. INTERVENTION CHARACTERISTICS

 Evidence Strength & Quality

+ 2

“I think the staff really find them beneficial. It gives them an opportunity to talk and brainstorm together as a team to come up with interventions … It helps to talk about it and know that we are listening.” (03)

+ 2

“[Huddles] really are probably one of the stronger solutions of building a strong team and fostering a compassionate workplace. And ultimately, what that benefits is the care that we provide at the frontline. And that’s what we want.” (14)

**

 Relative Advantage

+ 2

“Shift report is only [going] through what happens to residents, their health status, what we should delegate and pay attention to. Huddles are more like solving, brainstorming. Sometimes it’s just one little problem on the unit and it causes everyone trouble … Once we eliminate that, everybody has a better day.” (20)

+ 1

“There was no actual formal process to [previous debriefing]. They maybe recognize that we’re doing it in an informal way, but I don’t think they recognize the importance of doing it formally, and doing it consistently, and how impactful it really truly can be.” (14)

*

 Complexity

2

“It wasn’t this big meeting that people had to stop their work and interrupt their work plan – it was something that we could do short-term for them.” (01)

+ 1*

“I don’t think I would see it [as complex]. I think it was a very logical way of supporting the staff and practical way of supporting staff during a very stressful time, to have that opportunity for staff to be heard.” (10)

*

 Design Quality & Packaging

+ 2

“The [materials] were useful. We used the [whiteboards] to put down ideas or put down questions. And sometimes when a huddle is done, when I get back to the unit there is a new question or a new suggestion on it, and I’m like, “Okay, well that’s good.” It gives people a place to put down their ideas or their questions. So, it was good. The materials provided were good.” (07)

+ 1

“That was really helpful. I think that really supported the work and supported the intervention, so I wasn’t having to make up themes and topics, etcetera. And the tools for feedback and completing that feedback, those were incredibly helpful. Really helped to be able to consolidate the information and put notes. I think I would have been lost without those tools.” (09)

*

II. OUTER SETTING

 Needs & Resources of Those Served by the Organization

- 2

“Everybody is working hard, and they have a list of things to do, so can they or do they have time to stop doing that and add another [thing] on the plate? So, that’s the challenge. So, I think that the willingness is there, it’s just the logistics of finding [participants]” (05)

- 2

“Again, we’re going back to not having enough staff… If I had a fourth person, I could add five minutes onto the morning report. You see? Because those five minutes will get lost in a way, because there is more staff, and it will get done much faster.” (17)

**

III. INNER SETTING

 Communication

+ 2*

“I found coming to this home, I thought, ‘Boy, they really communicate well.‘ So, outbreaks updates; the administrator did a full report, that was sent out regularly; they communicated point-click-care; they have a Facebook group. So, there were multiple forms of communications available.” (06)

- 2*

“[Leadership] will send out this email… But the majority of the PSWs don’t read their emails. They don’t have time during their shift to read their emails. RPNs read their emails because they’re doing charting, they’re on their computer; PSWs aren’t… It’s come up multiple times at meetings, “What can we do to get this message out to staff?” And we’re all drawing blanks.” (12)

**

 Culture

- 1

“[Staff] just need to come forward and ask, and they need to have confidence to know that they can do that, they’re allowed. And I think that we have an open enough organization that that can be instilled… We need to work on that one for sure.” (02)

+ 1*

“[Leadership] wants staff to connect. We have the idea of staff connection. To connect, they need to know what’s happening, and what happened yesterday… And I think [staff] like that, anything that will improve the work for us.” (16)

*

 Implementation Climate:

1. Tension for Change

+ 1*

“Well, I think if we could do it now, this year like we did, in the state we’re in, I think that shows a lot. Because hopefully things are going to get better and it’s going to get much easier to fit into the day-to-day.” (03)

- 2

“I think they see it as a pain in the butt, ‘What is the value in this?’ And that’s always the challenge with anything new that you want to implement – it’s the buy-in… And so, that is a barrier to begin this.“ (14)

**

 Implementation Climate:

2. Compatibility

+ 2*

“Absolutely [huddles fit within the home]. I think they fit in any long-term care home to be honest with you… Because often they’re nursing-focused. So having the whole team – the dietary, the program activity people, the housekeepers, the nursing teams – that’s really effective. Because then they are part of the team.” (04)

- 2*

“I don’t know if there would ever be a right moment to do it, that’s for sure. So, I can see some struggle in implementing it, but I’m not sure that waiting is necessary and would make it better.” (11)

**

 Implementation Climate:

3. Relative Priority

- 2*

“And it’s just that struggle to meet the basic care needs. There’s a lot of quality improvement things that can be introduced but it’s introducing them properly that they’re going to work well, right? And when you’re just trying to make the basic needs everyday it kind of stops you in your tracks from what you want to do.” (19)

- 2

“For every minute you take to do something else, you’re taking away from care that could be provided to residents. So, every minute that you’re in a meeting, every minute that you’re in a huddle today is a minute that you’re not participating in taking care of somebody. And so, there’s an opportunity lost there, when you’re having a huddle.” (12)

**

 Implementation Climate:

4. Organizational Incentives & Rewards

Missing

- 1

“Staff are not really happy or maybe not really fully engaged [with huddles] because of the tasks that they need to complete. And we’re going to be questioning them as leaders or management if they don’t complete their tasks.” (16)

 Readiness for Implementation:

1. Leadership Engagement

- 2*

“I’m concerned about the nursing management team, because to me they should be one of the people that to continue to lead the huddles going forth. And I’m not sure if they’re ready – not even ready, but hopefully they will be able to keep the sustainability of it.” (04)

- 2

“I think it would have been helpful to have presence of management and leadership at these huddles… Even if there was an opportunity moving forward, that management were at so many huddles, or once a month, or whatever that looks like. Or if there were certain triggers – a patient safety issue, etcetera – what would trigger management to then come into these huddles? Because I think their presence really is important” (09)

**

IV. CHARACTERISTICS OF INDIVIDUALS

 Knowledge & Beliefs about the Innovation

+ 2*

“I haven’t heard anything negative about it. I haven’t heard any negative feedback… I do think, just in general, most staff are receptive to anything that’s going to help them in the long run. I think we have a pretty good team here, and they do overall work well together. So hopefully with the extra support, that will help further.” (06)

+ 2*

“I think it was a very logical way of supporting the staff and practical way of supporting staff during a very stressful time, to have that opportunity for staff to be heard… I think they can help to keep relationships strong amongst the teams. Because ultimately, I do believe the stronger the teams, the better the care and the better the work experience and living experience for residents.” (10)

*

 Self-Efficacy

- 2*

“It felt like [staff] were happy with nurse practitioner to be asking questions and to be leading how the meeting goes and answering and giving ideas. Rather than taking that role and start asking everybody… I think some people don’t want to be doing anything other than their position at work, like PSWs and other people.” (20)

0

“I did try to encourage the staff, “Now that you’ve seen what we’ve done, you guys can all do this on your own. If you have a concern about a resident, think about how you could pull together your own little group and do that.” And I don’t know if that continues.” (09)

*

 Individual Identification with Organization

- 2*

“I don’t want to say PSWs are the lower rung, but we feel that way sometimes – one of the upper ones got to hear and see, “Oh. Well, that’s a simple fix.” Then they got to jump over to a different department, and they got to fix it. Instead of the other department going, “Well, I’m not changing that on a PSW’s say.” (21)

0

“And sometimes, I talk to the girls, “As long as we do our job, they’re not going to give us more staff.” But you see, our souls cannot not finish the job because this is why we are there. We are there because we want to help people.” (17)

*

 Other Personal Attributes

+ 2*

“The nurse practitioner is a good leader… because she’s very positive, she’s very knowledgeable and she actually gets things done… And she listens. We feel that she listens.” (21)

- 1

“During an outbreak or in the midst of the pandemic, I can see how that would be very helpful. I think post-pandemic, it’s maybe a little bit different. You’re talking about different things. And I think some of the topics that we wanted staff to talk about require personal relationships with their team and with the person who is leading the huddle.” (10)

**

V. PROCESS

 Engagement

+ 1*

“It’s probably going to be 60:40 with 60 [percent of staff] being the positive… Like I said, everybody has different problems and different personalities. I think for the most part, it’s going to help. Going to give a 60:40, but it all depends too on who can facilitate the huddles for those other 40% strong personalities.” (05)

+ 1*

“I think some [staff are receptive to huddles], yes, some of them not. It’s something new – some people don’t want because they like to work by themselves. Some people are more together. If you work together, it’s much easier.” (15)

*

 Engagement:

1. Opinion Leaders

- 2

“The recreational therapy manager… her group are a very important part of the team… I pulled her into one huddle… [Instead of engaging,] she felt like she needed to explain why they do the work they do, why they’re not available all the time, that they have to do charting too.” (01)

0

“I honestly believe that a huddle is only going to work on a floor where you’ve got supervisor buy-in for it. If you don’t have a team lead or an RN who is buying into it and making time for it, it’s not going to happen on the floor.” (12)

*

 Engagement:

2. Champions

- 1*

“Some people don’t want to step out and start leading the huddles. The environment of the group on the unit is usually that the RPN is the lead and PSWs, they usually do not. And they always say, ‘That’s why we don’t want to be a nurse, because we don’t want the responsibility’… Nobody really wants to step out of their role and do something else.” (20)

- 2*

“But I (NP) did ask them to look to [continue the huddles] and I tried to build the capacity like, ‘You don’t need me here to do these huddles, you guys can do these independently. Think of what it would look, think of how I’ve done these.’ So, I did work hard to build that capacity and that independence so that they could do these huddles outside of just having me present… And I don’t know if that continues.” (09)

**

 Engagement:

3. Innovation Participants

+ 2*

“So, it’s really effective to have from your dietary to your housekeeper to resident support aides all contributing towards the [same] goal… When they’re a part of that huddle, that they’re all members of the team. And I believe in and always say that we all need each other to function as a unit.” (04)

X

“I think some of them [are engaged], yes, some of them not. It’s something new – some people don’t want because they like to work by themselves. Some people are more together.” (15)

*