Contextual factors
’s long-term sickness, vulnerability.
SIL
The study took place within the context of multiple pressures in all wards. Staffing issues were common. Ward A had extra beds on the ward, low staffing levels, and a lack of senior staff due to the ward manager’s long-term sickness:This leaves the ward unsafe and staff are struggling to carry out their required duties never mind embrace change and add to their workload (SIL, Ward A)This created barriers to implementing PERFECT-ER. Staff changes meant SILs needed to constantly engage with and inform new colleagues about PERFECT-ER practices on the ward.The implementation climate in the inner setting involved a lack of interest from some staff members and resistance to change, which reflected points of implementation vulnerability.…at times [it] would demotivate me seeing the lack of engagement from the other staff. (SIL Report, Ward D)…when the nursing numbers have been so diminished any extra, anything which seems like it might involve extra work is really resisted (PL, Ward A)These quotes reflect the relative low priority of PERFECT-ER among staff.Similarly, organisation-level changes could be slow to materialise leaving ward-level changes difficult to enact in isolation.…it takes time for things like documentation groups to approve these things, Trust-wide approaches and they don’t want individual approaches on Wards (PL, Ward E)Lessons learnt from this process evaluation to address consistency in intervention implementation and participant retention for a future definitive trial are reported in PERFECTED: lessons learnt for a future definitive randomised controlled trial.