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Pet robots are technology-based substitutes for live animals that have demonstrated psychosocial benefits for people living with dementia in long-term care. However, little research has been conducted to understand how pet robots should be implemented in routine care. This study aims to identify, contextualize, and achieve expert consensus on strategies to implement pet robots as part of dementia care in long-term care facilities.
Design
A 2-round modified Delphi study.
Settings and Participants
An international panel of 56 experts from 14 countries, involving care professionals, organizational leaders, and researchers.
Methods
A list of potentially relevant strategies was identified, contextualized, and revised using empirical data and through stakeholder consultations. These strategies constituted statements for Round 1. Experts rated the relative importance of each statement on a 9-point scale, and free-text fields allowed them to provide justifications. Consensus was predefined as ≥75% agreement. Statements not reaching an agreement were brought forward to Round 2. Quantitative data were analyzed using descriptive statistics, and textual data were analyzed using inductive content analysis.
Results
Thirteen strategies reached consensus; 11 were established as critical: (1) assess readiness and identify barriers and facilitators, (2) purposely reexamine the implementation, (3) obtain and use residents' and their family's feedback, (4) involve residents and their family, (5) promote adaptability, (6) conduct ongoing training, (7) conduct educational meetings, (8) conduct local consensus discussions, (9) organize clinician implementation team meetings, (10) provide local technical assistance, and (11) access new funding. Other strategies received differing extents of agreement. Reasons for variations included contextual differences, such as resource availability, organizational structures, and staff turnover.
Conclusions and Implications
This study identified the most relevant strategies that can be used by technology developers, care providers, and researchers to implement pet robots in long-term care facilities for dementia care. Further development, specification, and testing in real-world settings are needed.
They have also expressed the lack of (and need for) meaningful and individualized activities, desires to maintain previous life roles, and to experience freedom and choice.
Pet robots were developed nearly 3 decades ago to support the psychosocial health of PLWD. Numerous studies have demonstrated the use of pet robots as a promising psychosocial intervention for PLWD in LTC, such as reducing agitation, and improving mood and social interactions.
Effects on symptoms of agitation and depression in persons with dementia participating in robot-assisted activity: a cluster-randomized controlled trial.
The usability and impact of a low-cost pet robot for older adults and people with dementia: qualitative content analysis of user experiences and perceptions on consumer websites.
Despite more than a decade of research to evaluate their impacts, there is a dearth of knowledge on the “how” to translate them into practice. To support their uptake as a part of routine dementia care, it is vital to advance knowledge on their implementation to minimize the research and practice gap.
Principles of effectiveness trials and their implementation in VA Cooperative Study# 430: ‘Reducing the efficacy-effectiveness gap in bipolar disorder’.
The review was guided using the Consolidated Framework of Implementation Research (CFIR), a determinant framework that guides the comprehensive exploration of 39 constructs within 5 domains that can influence the implementation of interventions
: (1) intervention characteristics, (2) outer setting (determinants external to the organization), (3) inner setting (determinants related to characteristics of the organization), (4) characteristics of individuals involved in implementation, and (5) implementation process. Among 53 included articles, 23 were conducted in LTC for older adults and PLWD. Implementation determinants were mapped onto 18 CFIR constructs. They included different preferences for robot designs, cost, (in)compatibility with work processes, time and manpower, and differing attitudes from family and care providers. Most studies were focused on understanding determinants relating to the intervention characteristics, with significantly less focus on other domains, such as organizational attributes or external influences. Consequently, a qualitative study was conducted to further explore the determinants of implementing pet robots in nursing homes for dementia care,
where attention was paid to understanding gaps identified from the review. Determinants were mapped onto 28 CFIR constructs. Examples include costs, external funding and policies, resources, organizational or regulatory mandates, and conflicting stakeholder views.
This study aimed to establish expert consensus on the most relevant (important) strategies for implementing pet robots in LTC facilities for dementia care, based on implementation determinants established from the preceding studies. We operationalized “consensus” as the level and extent of agreement among experts.
and briefly described here. The Expert Recommendations for Implementing Change (ERIC) and the CFIR-ERIC mapping tool were used to guide the study. ERIC comprises 73 implementations strategies
organized into 9 conceptually distinct categories: develop stakeholder interrelationships, evaluative and iterative strategies, train and educate stakeholders, adapt and tailor to context, provide interactive assistance, engage residents and their family members, use financial strategies, support clinicians, and change infrastructure.
Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study.
is a tool to match CFIR determinants to implementation strategies in ERIC. The mapping process generates a list of potentially relevant strategies, ranked based on each cumulative percentage generated by the tool's algorithm. The algorithm aggregates the proportion of participants (involved in the tool's development) who endorsed the strategy's applicability to address each CFIR determinant. A higher percentage indicates the strategy's potential relevance in addressing implementation determinants. The Guidance for Conducting and REporting Delphi studies (CREDES) guidelines
: organizational leaders with leadership positions in LTC facilities and care professionals with experience providing care for residents with dementia were chosen for their context-specific, experience-based expertise.
These LTC facilities included nursing homes and care homes that provide personal and/or skilled care for residents. Researchers with expertise in psychosocial interventions for people with dementia, social robots, and implementation research in LTC were included for their topic-based expertise.
Experts were identified from multiple avenues, including contact with LTC organizations, professional bodies, a trans-European research network, peer-reviewed publications, social media, and personal connections. Our target sample size was 42 experts, based on recommendations from previous studies.
However, we aimed to minimally recruit 54 experts to account for at least 20% attrition. All eligible participants were invited to participate through individual emails, containing an invitation letter and an information sheet. Informed consent was obtained.
Statement Development
Initial statements for the modified Delphi study were developed using empirical and conceptual data. Implementation determinants were identified from a preceding scoping review
that were guided using the CFIR. These were mapped onto the ERIC taxonomy using the CFIR-ERIC tool. Strategies with a cumulative percentage of >100% were selected for potential inclusion. As each strategy's name and description were intended to be generic, they were contextualized using empirical data from preceding studies (ie, tailored to the context of implementing pet robots for dementia care in LTC). This was led by author WQK, and verified by VH to minimize subjectivities. Disagreements were discussed and resolved. Next, key stakeholders (3 care professionals, 1 organizational leader, and 1 academic researcher) were consulted through individual, informal meetings. An advisor (individual with dementia) from the Dementia Research Advisory Team was also consulted about implementation strategies from the “engage residents and their family members” category. Strategies and their descriptions were presented: stakeholders commented on their readability and clarity, and suggested revisions. All were invited to pilot the survey, except for our advisor from the Dementia Research Advisory Team, because the survey was not adapted to ensure cognitive accessibility for PLWD. As only 2 were able to contribute to the pilot, another researcher and health care professional were invited for piloting. Feedback was sought regarding the survey layout and user experiences, and amendments were made accordingly.
Data Collection and Analysis
Round 1
Demographic information was collected. A summary of implementation determinants was provided before the list of 48 implementation strategies was presented. Participants were invited to rate the relative importance of each strategy on a 9-point Likert scale (1–3: little importance, 4–6: important, not critical, 7–9: important and critical). Free-text fields were available for justifications or suggestions to revise the description of each strategy. The survey remained open for 3 weeks, and up to 3 individualized reminder emails were sent.
Descriptive statistics were used to describe participants’ demographic, percentage agreement, and central tendency.
Consensus was predefined as ≥75% agreement on the relative importance of statements. Free-text comments for each statement were analyzed separately using inductive qualitative content analysis, for the purpose of providing feedback in Round 2. WQK familiarized herself with the data by reading all responses and then developing low-inference codes for each statement. To further structure the data, responses were sorted into 3 categories based on whether they were (1) in support of the strategy, (2) not in support or expressed limitations, and (3) suggestions for revision. Statements that were not agreed on were amended based on suggestions and brought forward to Round 2 for revoting. Newly suggested strategies were mapped onto the list of ERIC strategies: if the suggested strategy had already been included, the suggested strategy was not included. Otherwise, they were listed as additional strategies and included as new statements for Round 2. The Kruskal-Wallis test was conducted to identify statistically significant differences (P ≤ .05) in responses between expert groups.
Round 2
A summary of the results in Round 1 was presented alongside each statement that did not reach agreement and new statements were presented for voting. Quantitative data analysis followed the process described in Round 1. The stability of consensus, defined as “the consistency of responses between successive rounds,”
To understand the variations in levels of agreement, textual data from both rounds were analyzed as a whole using inductive qualitative content analysis.
WQK familiarized with the data by re-reading them to have a sense of the data as a whole, before assigning descriptive, open codes to the data. Data that were assigned to each code, were reexamined and organized into subcategories and categories.
Results
Statement Development
Implementation determinants were identified from 28 CFIR constructs and mapped onto the CFIR-ERIC tool. Fifty-five strategies were selected and brought forward for contextualization, resulting in 3 main changes. First, terms in the original strategies were amended to align with the context of our study. For instance, generic terms and jargon such as “service formularies” and “patients” were described by stakeholders as being difficult to understand or poorly termed. These were re-termed. Next, 7 strategies were either removed or combined with other strategies based on stakeholders’ suggestions, due to overlapping descriptions or irrelevance to our context. Finally, the list of implementation strategies was re-ordered. Instead of presenting the strategies in order of their potential relevance (ie, cumulative percentage scores), which led to cognitive overload and recall difficulties for stakeholders during consultation sessions,
the strategies were grouped based on their similarities and/or sequentially. Overall, 48 strategies constituted the initial statements for Round 1. Supplementary File 2 shows the original and contextualized strategies.
Round 1
Of 121 invited participants, 66 agreed to participate. Fifty-six completed Round 1 (response rate: 84.8%). The average completion time was 50 minutes. Table 1 summarizes the experts’ demographic information. Four experts belonged to more than 1 professional group.
Table 1Demographic Information
Characteristics
No. of Experts
Round 1
Round 2
Roles
Care Professionals
22
21
Activity Coordinator
7
5
Assistant Psychologist/Clinical Psychologist
2
3
Healthcare Assistant/Nursing Aide
3
1
Nurse
3
5
Occupational Therapist
5
5
Physiotherapist
1
1
Social Worker
1
1
Organizational Leaders
17
15
Activity Director
1
-
Assistant/Clinical Nurse Manager
1
2
Assistant/Care Home Manager
5
3
Clinical Lead for Care Home Liaison Service/Support Manager (Residential Aged Care)
2
2
Director/Head of Nursing, Care Homes and/or other services
7
7
Quality in Care Lead/Nursing Inspector
1
1
Academic Researchers
24
22
Assistant/Associate Professor/Professor
10
10
Doctoral Researcher/Research Assistant
6
5
Lecturer/Senior Lecturer
1
1
Post-Doctoral Researcher/Senior Scientist
4
3
Practice Development Consultant
0
1
Project Manager
1
1
Researcher-in-Residence
1
1
Care Professionals (Years of experience)
-
Practicing as a care professional
Less than 1 year
1
1 year to less than 3 years
4
3 years to less than 7 years
4
7 years to more than 9 years
13
Working in a care home/nursing home context
Less than 1 year
3
1 year to less than 3 years
5
3 years to less than 7 years
4
7 years to more than 9 years
10
Organizational Leaders (years of experience)
Working in a care home/nursing home context
Less than 1 year
2
1 year to less than 3 years
2
3 years to less than 7 years
2
7 years to more than 9 years
12
Leadership/management in a care home/nursing home context
Six strategies (12.5%) reached consensus, with participants rating all as important and critical. Table 2 shows a summary of the results. There was no statistically significant difference between the expert groups in their responses except for 2 strategies: “use an implementation advisor” and “tailor strategies.” Researchers rated the former as important and critical (median score: 7), and care professionals rated it as important but not critical (median score: 5) (P = .029). The latter was also favored more by researchers (median score: 8) than by organizational leaders (median score: 6) (P = .028).
Table 2Summary of Results (Rounds 1 and 2)
Round 1
Round 2
Change Between Rounds
Mean
SD
Level of Agreement, %
Mean
SD
Level of Agreement, %
R1-R2 Change in SD
Stability (<15% Change in SD)
Category 1. Develop Relationships between Internal and External Stakeholders
Free-text comments on the remaining 42 strategies were used to modify their descriptions (Supplementary File 3). Twenty-nine “additional strategies” were proposed: 21 could be mapped onto the list of existing strategies, and 3 were generic comments and were therefore not included as new strategies. The remaining 5 were categorized into 2 additional strategies within the “support clinicians” strategy group and carried forward to Round 2 along with the 42 revised strategies. Figure 1 summarizes the study flow.
Fifty-two experts completed Round 2 (response rate: 92.9%). Seven strategies reached consensus (15.9%). There was no statistically significant difference in the responses of different expert groups. The stability of consensus was assessed for the 42 strategies brought forward from Round 1. Thirty-four strategies achieved stability (81.0%). The standard deviations of 29 strategies (69.0%) decreased between rounds, suggesting a shift toward convergence of group opinions for most strategies.
However, the standard deviations of the remaining 13 strategies (31.0%) increased, suggesting a shift toward opinion divergence.
Most Relevant Strategies for Implementing Pet Robots
A summary of 13 strategies that achieved consensus and their relative importance is shown in Table 3. A detailed description of these strategies can be found in Supplementary File 4. Twelve strategies were important and/or critical: (1) assess readiness and identify barriers and facilitators, (2) purposely reexamine the implementation, (3) obtain and use residents' and their family's feedback, (4) involve residents and their family, (5) promote adaptability, (6) conduct ongoing training, (7) conduct educational meetings, (8) conduct local consensus discussions, (9) organize clinician implementation team meetings, (10) provide local technical assistance, (11) access new funding, and (12) develop resource sharing agreement. Experts expressed that strategy “alter incentives/allowances structure” may lead to the inappropriate use of robots and had little importance: “… all incentivizing robots will get you is lots of people being forced to use robots who receive no benefit/are harmed by them.”
Table 3List of the Most Relevant Implementation Strategies
Implementation Strategy
Mean
Median
IQR
ERIC Taxonomy Category
Rank (CFIR-ERIC)
Important and critical
1
Assess readiness and identify barriers and facilitators
Variations in the Extent of Agreement Among Experts
Strategies that did not reach consensus are grouped based on the level of agreement and summarized in Table 4. There was near consensus (70% to <75% agreement) on 10 strategies, moderate agreement (60% to <69%) on 10 strategies, and low agreement (40% to <59%) on 17 strategies. To understand variations in experts’ responses, 620 and 293 free-text comments were gathered from Rounds 1 and 2, respectively, analyzed, and grouped into 5 categories.
(1)
Buy-in from local stakeholders
Table 4Extent of Agreement for Implementation Strategies That Did Not Achieve Consensus
Implementation Strategy
Mean
Median
SD
IQR
Level of Agreement, %
Level of Importance
ERIC Taxonomy Category
70% to ≤75% agreement (Near consensus)
Conduct cyclical small tests of change
7.12
7
1.263
2
73.10
Important and critical
Evaluative and iterative strategies
Tailor strategies
7.04
7
1.715
2
73.10
Important and critical
Evaluative and iterative strategies
Develop educational materials
6.98
7
1.321
2
71.20
Important and critical
Train and educate
Audit and provide feedback
6.96
8
1.76
2
73.10
Important and critical
Evaluative and iterative strategies
Conduct local needs assessment
6.85
7
1.764
2
73.10
Important and critical
Develop stakeholder interrelationships
Use train-the-trainer strategies
6.79
7
1.377
2
73.10
Important and critical
Train and educate
Facilitate relay of clinical data to care providers
6.71
7
1.538
2
73.10
Important and critical
Support clinicians
Develop, test and introduce quality monitoring tools and system(s)
5.98
6
1.852
3
73.10
Important and critical
Evaluative and iterative strategies
Visit other sites
5.04
5
1.644
2
73.10
Important (not critical)
Develop stakeholder interrelationships
Shadow other experts
4.92
5
1.493
2
73.10
Important (not critical)
Train and educate
60% to ≤70% agreement (Moderate level of agreement)
Make training dynamic
7.02
7
1.244
2
69.20
Important and critical
Train and educate
Stage implementation scale-up
6.98
7
1.306
2
69.20
Important and critical
Evaluative and iterative strategies
Identify early adopters
6.52
7
1.421
1
61.50
Important and critical
Develop stakeholder interrelationships
Involve governance
6.35
7
1.919
3
61.50
Important and critical
Develop stakeholder interrelationships
Develop academic partnerships
5.73
5.5
1.43
2
67.30
Important (not critical)
Develop stakeholder interrelationships
Use an implementation advisor
5.04
5
1.571
2
65.40
Important (not critical)
Develop stakeholder interrelationships
Work with Educational Institutions
4.58
5
1.661
2
65.40
Important (not critical)
Train and educate
Conduct educational visits
4.56
5
1.673
2
61.50
Important (not critical)
Train and educate
Use mass media
4.42
5
1.764
3
67.30
Important (not critical)
Engage residents and their family members
Obtain formal commitments
4
4
1.358
2
61.50
Important (not critical)
Develop stakeholder interrelationships
40% to ≤60% agreement (Lower level of agreement)
Identify and prepare champions
6.6
7
1.648
3
59.60
Important and critical
Develop stakeholder interrelationships
Distribute educational materials
6.58
7
1.625
2
57.70
Important and critical
Train and educate
Capture and share local knowledge with other care homes/nursing homes
6.48
7
1.527
3
53.80
Important and critical
Develop stakeholder interrelationships
Develop a formal implementation blueprint
6.15
7
1.974
3
55.80
Important and critical
Evaluative and iterative strategies
Provide protected time to support clinicians
6.13
7
1.99
2
53.80
Important and critical
Support clinicians
Inform local opinion leaders
6.08
6
1.48
2
55.80
Important (not critical)
Develop stakeholder interrelationships
Use a facilitator
5.92
6
1.631
3
51.90
Important (not critical)
Provide interactive assistance
Fund and contract for pet robots
5.81
6.5
2.197
4
50.00
Important and critical
Utilise financial strategies
Build a coalition
5.71
6
1.419
2
59.60
Important (not critical)
Develop stakeholder interrelationships
Create a learning collaborative
5.63
6
1.981
3
50.00
Important (not critical)
Train and educate
Place pet robots on fee-for-service lists of the care home/nursing home
This category describes the overall expert agreement that buy-in from local stakeholders (residents, their family, organizational leaders, and staff) was important to support the consistent and sustainable adoption of pet robots. Experts expressed that stakeholders should understand the reasons behind using pet robots and have opportunities to discuss their thoughts: “The most important people to get buy-in from,are care staff themselves. If they do not know why something is being done and are not given the opportunity to discuss and solve barriers, the intervention will fail [strategy: conduct local consensus discussions].” Some added that seeing their benefits would facilitate buy-in: “very helpful for staff to see the use of pet robots in their care home to get buy-in. If one resident has a pet robot, others often want it [Strategy: Inform local opinion leaders].”
(2)
Building local capacity
This category describes varied views on strategies to build capacity within an organization to support the adoption of pet robots. Some experts advocated for strategies to support “selected individuals” (such as champions) to facilitate implementation. Others doubted their practicability because of considerations like culture, individuals' attributes, and staff turnover: “I've seen many homes where they have a champion strategy, and when that person leaves no one uses the robots anymore [strategy: identify and prepare champion].” Correspondingly, some expressed preferences to invest in strategies to build the skills of all staff. The viability of strategies also may be influenced by organizational size. Some expressed that educational materials were valuable; however, others felt they may not engage staff: “many care home staff are experiential learners and may not value written information [strategy: distribute educational materials].” Experts underlined the importance of interactive, practical training: “staff are poorly paid, have very difficult jobs, and deal with acute situations that need their attention. This just won't be high on their priority list, so it needs to be engaging [strategy: make training dynamic].” Nevertheless, some expressed that training was not crucial considering competing work demands, because staff have general skills to deliver interventions.
(3)
Considering organization context and processes
This category describes how organizational contexts influenced experts’ ratings. Understanding the organizational context was described as important: “Some care homes have regular living dog visits or other animal-related activities… So this could be one of the barriers of implementation [strategy: assess readiness and identify barriers and facilitators].” Strategies involving developing implementation plans, evaluation, and involving governance were favored by some, who also expressed that such strategies should be simple or be integrated into existing workflows. Others were concerned about them being overly bureaucratic, complicated, or resource straining: “… I worry that this may add to increased documentation and bureaucratization of care work and take time away from actually using the robots and caring for residents [strategy: audit and provide feedback].” Because financial resources were described as limited, funding was crucial.
(4)
Involving external organizations and stakeholders
This category describes varied opinions on the importance of involving external organizations and stakeholders. Some highlighted the importance of knowledge exchange; however, there may be market competition: “There is often a degree of competition between care home providers… it may take time before they share information about a product that gives them a recognizable improvement in the care they deliver for people with dementia [strategy: build a coalition].” Considerations about existing networks also led to expert opinion variations: “… whereas big organizations can leverage sharing of resources within their many homes [strategy: build a coalition].” Although collaborations with other organizations like academic institutions were valuable, some perceived this as inaccessible. Some acknowledged the value of external stakeholders (eg, researchers); however, others expressed skepticism that external experts rarely understand the reality of care homes, and staff may be resistive: “… the perception that we need more training (generally from non-care home ‘experts’) to train staff, for me, has ran its course and we need to challenge this notion—it perpetuates low order status in our health and social care systems [strategy: conduct educational meetings].”
(5)
Supporting person-centered care provision
This category describes agreement that the implementation of pet robots should support person-centered care, including considerations about residents’ preferences, values, and current and evolving needs, and adapt pet robot use correspondingly: “It is vital that robots are introduced in response to unmet needs.. . to be ascertained through needs assessment for individual people with dementia [strategy: conduct local needs assessment].” Some experts also reported concerns about strategies placing excessive focus on pet robots, which could deter person-centered care: “These can actually be counterproductive, eg, they drive the implementation of robots, not good dementia care. The end becomes getting the robots in place to tick the box… [strategy: use advisory board and workgroups].”
Discussion
This study aimed to identify, contextualize, and achieve consensus on the most important strategies for implementing pet robots in LTC for residents with dementia. Twelve strategies were established as being most relevant for implementing pet robots, and variations in the extent of agreement were outlined. Reasons included a myriad of considerations, such as the accessibility of strategies, contextual differences like organizational structures, and staff turnover. Strategies achieving consensus appeared to accommodate such variations.
Strategies that achieved expert consensus were strategies that primarily involved local stakeholders within the care organization. These strategies appear to take into consideration organizational contextual factors common across different care organizations. Therefore, they may be more sustainable and less likely to be influenced by factors such as staff turnover, dynamic work environments, and resource constraints. Many studies suggest that LTC staff are often overworked and experience a higher level of burnout compared with the general population,
It is therefore unsurprising that strategies involving collective staff members reached agreement by panelists compared with those that involved identifying and training selected individuals (eg, champions).
Although previous studies showed that developing and distributing educational materials were most frequently used as training and educational strategies,
Implementation of evidence-based, non-pharmacological interventions addressing behavior and psychological symptoms of dementia: a systematic review focused on implementation strategies.
In contrast, the 2 “train and educate” strategies (conducting educational meetings, making training dynamic) that achieved expert consensus provide staff with opportunities for active engagement through dialogue, and in practical, problem-based and solution-driven training.
These were considered pragmatic and flexible enough to account for the dynamic environment in LTC, such as workload and fast-changing situations that demand staff attention. Although strategies to explicitly involve residents and their family members were also agreed by panelists as being critical, a scoping review involving 88 studies showed that few studies explicitly involved PLWD and their caregivers in implementation and dissemination interventions.
Paradoxically, strategies that involved developing partnerships with external stakeholders and organizations received varying levels of expert agreement. This opposes findings from previous research showing that building partnerships was a frequently used strategy.
Implementation of evidence-based, non-pharmacological interventions addressing behavior and psychological symptoms of dementia: a systematic review focused on implementation strategies.
Although experts underlined the value of learning about how pet robots were implemented in other facilities, some experts expressed hesitancy to share information with their “market competitors” in care provision. This suggests that the nature of LTC facilities can influence the practicability of such strategies.
Strategies involving collaborations with other external organizations and stakeholders (eg, academic partners), also received mixed responses. Although such strategies were valued
in other studies, experts expressed concerns about their inaccessibility and understanding of LTC context, which can lead to change resistance by local stakeholders
As such, strategies involving external collaborators should be thoroughly considered and discussed with local stakeholders, which can support change readiness and minimize resistance.
it is unsurprising that “access new funding” was agreed on as a critical strategy. However, strategies to incentivize care providers were frowned on because of concerns about over prioritization or inappropriate use among other existing interventions. Residents with dementia have multiple needs and preferences,
As pet robots are one of several interventions used in LTC, the selection and use of strategies to implement pet robots should consider existing care processes and interventions.
Implications for Practice and Research
Few studies used conceptual frameworks or empirical evidence to select and test strategies for implementing psychosocial interventions for PLWD.
Implementation of evidence-based, non-pharmacological interventions addressing behavior and psychological symptoms of dementia: a systematic review focused on implementation strategies.
Our findings provide empirical evidence for researchers to systematically identify, consider, and test strategies for implementing pet robots for dementia care in LTC. More work is needed to further specify the strategies. Proctor and colleagues
suggested 7 key steps: (1) name it, (2) define it, (3) operationalize it, (4) specify the actor, (5) specify the action, (6) specify the target of the action, and (7) specify temporality. Because the purpose of our study was to identify a list of strategies, we focused on the first 2 steps. Each strategy can also be combined to form multifaceted strategies to address multilevel implementation determinants. Further research could also consider evaluating the mechanisms of change underlying these strategies.
Previous studies that leveraged on the CFIR-ERIC tool to identify implementation strategies in other study contexts did not make these steps explicit enough for us to replicate the process.
Furthermore, although the tool generated a “ranked list” of strategies likely to be more relevant in addressing implementation, it had limited utility in identifying the most important strategies for our study: of 12 strategies that were established as “important/critical,” only 3 were identified from the list of “top 12” strategies generated from the tool. By clearly demonstrating how we leveraged, contextualized, and operationalized the ERIC taxonomy and the CFIR-ERIC tool for the systematic selection of implementation strategies for pet robot implementation, we suggest a process that future CFIR-ERIC tool users could consider adopting for other study contexts.
Strengths and Limitations
Using the ERIC taxonomy enabled us to identify widely encompassing implementation strategies, and multiple data sources were used for contextualization. The low attrition rate (<10%) between rounds provides confidence in the validity of our findings. Involving international multilevel experts enriched our findings, as previous studies involving the development/selection of strategies appear to be research-driven.
It is possible that in-person meetings could lead to consensus on more strategies; however, this is logistically challenging and would remove experts' anonymity, a strength of the Delphi technique. To mitigate this, participants’ comments were fed back to the panel anonymously. There is a higher representation of care providers from LTC organizations in the United Kingdom; however, considering that more than half of the experts were from outside the United Kingdom, our findings should be considered relevant in other national contexts. Although PLWD in LTC may be able to provide valuable experience-based perspectives, we did not include them in the panel of experts. Many have more advanced dementia, and participation in iterative, online surveys could cause distress. To mitigate this limitation, we consulted a member from the Dementia Research Advisory Team to contextualize strategies specifically in the “residents and their family members” category.
Conclusions and Implications
We established 12 implementation strategies considered crucial for implementing pet robots for dementia care in LTC settings. This provides empirical evidence and guidance for care providers and researchers to systematically select, further specify, combine, and test strategies. Our study also advances the field of implementation research and implementation strategies by clearly demonstrating how the ERIC taxonomy and the CFIR-ERIC tool can be operationalized and contextualized.
Acknowledgments
We are very grateful to all experts for generously contributing their time and expertise, without whom the study would not have been possible. We would like to thank all stakeholders for their advice, input and contributions to the contextualization of the list of initial implementation strategies. We are also grateful to Dr Sandra Pew and Dr Fawn-Harrad from Enabling Research in Care Homes (ENRICH), and David Evans from the Contact, Help, Advice and Information Network (CHAIN) for their support during study recruitment.
Effects on symptoms of agitation and depression in persons with dementia participating in robot-assisted activity: a cluster-randomized controlled trial.
The usability and impact of a low-cost pet robot for older adults and people with dementia: qualitative content analysis of user experiences and perceptions on consumer websites.
Principles of effectiveness trials and their implementation in VA Cooperative Study# 430: ‘Reducing the efficacy-effectiveness gap in bipolar disorder’.
Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study.
Implementation of evidence-based, non-pharmacological interventions addressing behavior and psychological symptoms of dementia: a systematic review focused on implementation strategies.
This work was supported by the Marie Curie Innovative Training Network (ITN) action, H2020-MSCA-ITN-2018, under grant agreement number 813196. The funder had no role in the design, conduct, and writing of this paper.
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