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Background  Fidelity in complex behavioral interventions is underexplored. This study examines the fidelity of the INFORM trial and explores the relationship between fidelity, study arm, and the trial’s primary outcome—care aide involvement in formal team communications about resident care.    Methods  A concurrent process evaluation of implementation fidelity was conducted in 33 nursing homes in Western Canada (Alberta and British Columbia). Study participants were from 106 clinical care units clustered in 33 nursing homes randomized to the Basic and Enhanced-Assisted Feedback arms of the INFORM trial.    Results  Fidelity of the INFORM intervention was moderate to high, with fidelity delivery and receipt higher than fidelity enactment for both study arms. Higher enactment teams experienced a significantly larger improvement in formal team communications between baseline and follow-up than lower enactment teams ( F (1, 70) = 4.27,  p  = .042).    Conclusions  Overall fidelity enactment was associated with improvements in formal team communications, but the study arm was not. This suggests that the intensity with which an intervention is offered and delivered may be less important than the intensity with which intervention participants  enact the core components of an intervention . Greater attention to fidelity assessment and publication of fidelity results through studies such as this one is critical to improving the utility of published trials.

Examining fidelity in the INFORM trial: a complex team-based behavioral intervention