The disconnect between evidence and practice: a systematic review of person-centred interventions and training manuals for care home staff working with people with dementia

Out-of-hospital paramedic interactions with people living with dementia: a scoping review

BACKGROUND

Dementia encompasses neurodegenerative disorders that account for a global estimated healthcare expenditure of 1.3 trillion US dollars. In Australia, one in 12 people aged ≥65 has a diagnosis of dementia and it is the second leading cause of death. Paramedics play a crucial role in person-centred dementia care, particularly in the community. While consensus has been established on paramedicine's integration into interdisciplinary care teams, there remains a lack of clarity regarding the paramedic role in dementia care.

OBJECTIVE

This study aimed to examine and report paramedic interactions with people living with dementia in the out-of-hospital setting.

DESIGN AND SETTING

This was a scoping review study of paramedics and people living with dementia within the out-of-hospital setting.

METHODS

This study was guided by the Joanna Briggs Institute (JBI) scoping review framework. Databases were searched without date limits, up to 4 April 2023. These encompassed OVID Medline, CINAHL, Scopus, APA PsycInfo and OVID Embase. Articles were included if they were primary, peer-reviewed studies in English and reporting on paramedic-specific interactions with people living with dementia in the out-of-hospital setting. Data extraction was performed based on study setting, design, population and key findings.

RESULTS

Twenty-nine articles were included in the thematic analysis. Four themes emerged: need for training, patterns of attendances, patterns of documentation and the integrative potential of paramedicine. Paramedics reported feeling ill-equipped and unprepared in caring for patients living with dementia due to challenges in assessment and management of caregiver tensions. They were often called as a last resort due to poor service integration and a lack of alternative care pathways. Despite high conveyance rates, there was low incidence of paramedic interventions initiated. Underdocumentation of dementia and pain was found.

CONCLUSION

Emergency ambulance conveyance of people living with dementia is a surface reaction compounded by a lack of direction for paramedics in the provision of out-of-hospital care. There is a pressing need for establishment of research and educational priorities to improve paramedic training in dementia-specific skillsets.

Nurses' Shared Subjectivity on Person-Centered Care for Behavioral and Psychological Symptoms of Dementia in Nursing Homes

BACKGROUND

Person-centered care (PCC), an approach to healthcare that focuses on the individual needs, preferences, and values of patients, is particularly important in the context of caring for residents of nursing homes (NHs) with the behavioral and psychological symptoms of dementia (BPSD). However, implementing PCC in NHs varies widely due to individual staff, NH environment, and country factors, leading to heterogeneity in person-centered approaches.

PURPOSE

This study was designed to explore and gain insight into the shared subjective perspectives of nurses on providing PCC to manage BPSD in NHs in order to elicit a deeper understanding of how nurses interpret and approach the provision of PCC.

METHODS

Q methodology was applied to explore the subjective perspectives of nurses. Twenty-nine NH nurses with more than 3 years of experience in managing BPSD completed a Q-sorting task, categorizing 43 Q-samples into a normal distribution shape. Postsorting interviews were conducted after the participants had completed this task. The collected data were analyzed using centroid factor analysis and varimax rotation run within the PQMethod 2.35 program. Interpretation of the resulting factors was based on factor arrays, field notes, and interview data.

RESULTS

Four factors from the shared subjective perspectives of nurses related to PCC were identified, including (a) sharing information focused on details to update care strategies, (b) monitoring until the true needs of residents are identified, (c) awareness of interactive cues in relationships, and (d) connecting an individual's life pattern to their current care.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The findings highlight that a one-size-fits-all approach may not be suitable for all nurses and interventions, indicating that nurses should consider the applicable subjective frames to ensure the effectiveness of planned interventions. A need for PCC education that specifically addresses BPSD management is suggested, with the findings implying that a strong organizational climate with respect to PCC in managing BPSD should promote higher job satisfaction and commitment and reduce turnover rates among nurses in NHs. Facilitating the development of PCC interventions appropriate for BPSD management that encompass the various categories and ranges of NH settings and nursing phenomena is thus recommended.

Introducing a multicomponent staff training intervention to reduce antipsychotic medication: Care home management pre and post intervention views of systemic impact, and preliminary RE-AIM evaluation

OBJECTIVES

We explored views of care home managers when introducing PROCUIDA-Demencia a mixed-methods two-arm cluster randomised controlled pilot and clinical outcomes study aiming to optimise dementia care by introducing psychosocial interventions to reduce antipsychotic medication in care homes.

METHOD

We undertook secondary analysis of pre and post in-depth interviews conducted in summer 2018 with not-for-profit care home managers in Mexico who were allocated to the intervention group. Transcribed data were thematically analysed. Themes were mapped out with RE-AIM quality appraisal framework (Reach, Effectiveness, Adoption, Implementation and Maintenance) as preliminary evaluation to identify practice and future intervention development and evaluation.

RESULTS

Two pre- and three post-intervention themes were constructed. Participants reported measurable positive impact; one home built a new specialist dementia care unit and others hired a psychologist and psychiatrist to sustain the changes. Antipsychotic medication was reduced for some participating residents which also minimised cost burden on family members.

CONCLUSION

Funding, systemic working across families, clinical and social teams and effective systems of governance are urgently required to sustain models like PROCUIDA-Demencia. The RE-AIM preliminary evaluation outlined care home managers' long-term sustainable practice and positive impact on the dementia care system. These findings might inform staff retention strategies and care home systemic care practices. This evaluation is contributing to the Mexican Alzheimer's and other dementias plan.

Moving between doing and being-Meanings of person-centredness as narrated by nursing home managers. A phenomenological hermeneutical study

AIM

This study aimed to illuminate meanings of person-centredness as narrated by nursing home managers in nursing homes rated as highly person-centred.

DESIGN

A phenomenological hermeneutical approach was used.

METHODS

Twelve nursing home managers in 11 highly person-centred nursing homes in 7 municipalities in Sweden were included in this interview study. The findings were interpreted, reflected and discussed through the lens of Ricoeur.

RESULTS

Meanings of person-centredness could be understand as moving between doing and being through knowing, sensing, sharing and giving for person-centredness. These aspects contributed via knowledge, understanding, interaction and action that involved doing for and being with older persons through these caring dimensions. By moving between doing for, being with and being part of the overall nursing home narrative, knowing, sensing, sharing and giving could support the persons' identity in different ways. This may also contribute to sense-making, preserving dignity and promoting self-esteem when aiming to provide a good life for older persons in nursing homes, within an ever-present ethical frame.

NO PATIENT OR PUBLIC CONTRIBUTION

This study illuminated meanings of person-centredness as narrated by nursing home managers. No patient of public contribution was investigated.

Psychosocial interventions for reducing antipsychotic medication in care home residents

BACKGROUND

Antipsychotic medications are regularly prescribed in care home residents for the management of behavioural and psychological symptoms of dementia (BPSD) despite questionable efficacy, important adverse effects, and available non-pharmacological interventions. Prescription rates are related to organisational factors, staff training and job satisfaction, patient characteristics, and specific interventions. Psychosocial intervention programmes aimed at reducing the prescription of antipsychotic drugs are available. These programmes may target care home residents (e.g. improving communication and interpersonal relationships) or target staff (e.g. by providing skills for caring for people with BPSD). Therefore, this review aimed to assess the effectiveness of these interventions, updating our earlier review published in 2012.

OBJECTIVES

To evaluate the benefits and harms of psychosocial interventions to reduce antipsychotic medication use in care home residents compared to regular care, optimised regular care, or a different psychosocial intervention.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 14 July 2022.

SELECTION CRITERIA

We included individual or cluster-randomised controlled trials comparing a psychosocial intervention aimed primarily at reducing the use of antipsychotic medication with regular care, optimised regular care, or a different psychosocial intervention. Psychosocial interventions were defined as non-pharmacological intervention with psychosocial components. We excluded medication withdrawal or substitution interventions, interventions without direct interpersonal contact and communication, and interventions solely addressing policy changes or structural interventions.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Critical appraisal of studies addressed risks of selection, performance, attrition and detection bias, as well as criteria related to cluster randomisation. We retrieved data on the complex interventions on the basis of the TIDieR (Template for Intervention Description and Replication) checklist. Our primary outcomes were 1. use of regularly prescribed antipsychotic medication and 2.

ADVERSE EVENTS

Our secondary outcomes were 3. mortality; 4. BPSD; 5. quality of life; 6. prescribing of regularly psychotropic medication; 7. regimen of regularly prescribed antipsychotic medication; 8. antipsychotic medication administered 'as needed'; 9. physical restraints; 10. cognitive status; 11. depression; 12. activities of daily living; and 13.

COSTS

We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included five cluster-randomised controlled studies (120 clusters, 8342 participants). We found pronounced clinical heterogeneity and therefore decided to present study results narratively. All studies investigated complex interventions comprising, among other components, educational approaches. Because of the heterogeneity of the results, including the direction of effects, we are uncertain about the effects of psychosocial interventions on the prescription of antipsychotic medication. One study investigating an educational intervention for care home staff assessed the use of antipsychotic medication in days of use per 100 resident-days, and found this to be lower in the intervention group (mean difference 6.30 days, 95% confidence interval (CI) 6.05 to 6.66; 1152 participants). The other four studies reported the proportion of participants with a regular antipsychotic prescription. Of two studies implementing an intervention to promote person-centred care, one found a difference in favour of the intervention group (between-group difference 19.1%, 95% CI 0.5% to 37.7%; 338 participants), while the other found a difference in favour of the control group (between-group difference 11.4%, 95% CI 0.9% to 21.9%; 862 participants). One study investigating an educational programme described as "academic detailing" found no difference between groups (odds ratio 1.06, 95% CI 0.93 to 1.20; 5363 participants). The fifth study used a factorial design to compare different combinations of interventions to supplement person-centred care. Results showed a positive effect of medication review, and no clear effect of social interaction or exercise. We considered that, overall, the evidence about this outcome was of low certainty. We found high-certainty evidence that psychosocial interventions intended primarily to reduce antipsychotic use resulted in little to no difference in the number of falls, non-elective hospitalisations, or unplanned emergency department visits. Psychosocial interventions intended primarily to reduce antipsychotic use also resulted in little to no difference in quality of life (moderate-certainty evidence), and BPSD, regular prescribing of psychotropic medication, use of physical restraints, depression, or activities of daily living (all low-certainty evidence). We also found low-certainty evidence that, in the context of these interventions, social interaction and medication review may reduce mortality, but exercise does not.

AUTHORS' CONCLUSIONS

All included interventions were complex and the components of the interventions differed considerably between studies. Interventions and intervention components were mostly not described in sufficient detail. Two studies found evidence that the complex psychosocial interventions may reduce antipsychotic medication use. In addition, one study showed that medication review might have some impact on antipsychotic prescribing rates. There were no important adverse events. Overall, the available evidence does not allow for clear generalisable recommendations.

Professional caregivers' participation in the International Caregiver Development Programme: A qualitative study of psychosocial care in nursing homes

AIM

This paper aims to explore professional caregivers' experiences of psychosocial care for older persons living in nursing homes following the professional caregivers' participation in the International Caregiver Development Programme (ICDP).

DESIGN

A qualitative study.

METHODS

About 15 focus group interviews and 25 participatory observations of five ICDP group courses were conducted with 31 employees in nursing homes, including registered nurses, enrolled nurses and nursing aids. The findings emerged through hermeneutic analysis.

RESULTS

Main findings: (i) Adjusting the communication to the residents' psychosocial needs, (ii) Seeing the residents as individuals and (iii) Adjusting to individual interaction with the residents. The professional caregivers experienced that the residents participated more in communication, interaction and activities, in addition to be more satisfied, calm, happy and thankful in interaction with the caregivers. Furthermore, they described that the environment in the units became calmer and that they were considering psychosocial care before medication. Work-related stress seems to impact ICDP participation and may be a barrier to implementation.

Assessment of Labor Practices in Healthcare Using an Innovatory Framework for Sustainability

Background and Objectives: The concept of sustainability in healthcare is poorly researched. There is a perceived need for new theoretical and empirical studies, as well as for new instruments to assess the implementation of new labor practices in the field. Such practices address unmet social needs and consolidate the sustainable development systems which promote health equity. The objective of the research is to design an innovative reference framework for sustainable development and health equity of healthcare facilities, and to provide a practical validation of this framework. Materials and Methods: The research methods consist of designing the elements of the new frame of reference, designing an indicator matrix, elaborating indicator content, and assessing the reference framework. For the assessment stage, we used sustainable medical practices reported in the scientific literature as well as a pilot reference framework that was implemented in healthcare practice. Results: The new reference framework suggested by the present study is composed of 57 indicators organized in five areas: environmental responsibility, economic performance, social responsibility, institutional capacity, and provision of sustainable healthcare services. These indicators were adapted and integrated into the seven basic topics of the social responsibility standard. The study presents the content of the indicators in the field of labor practices, as well as their evaluation grids. The innovative format of the evaluation grids aims to describe achievement degrees, both qualitatively and quantitatively. The theoretical model was validated in practice through its implementation at the Emergency Hospital in Targu Mures. Conclusions: The conclusions of the study reflect the usefulness of the new reference framework, which is compatible with the requirements in the healthcare field, but differs from other existing frameworks, considering its objective regarding the promotion of sustainable development. This objective facilitates the continuous quantification of the sustainability level, the promotion of sustainable development strategies, and sustainability-oriented approaches on the part of interested parties.

A Feasibility Evaluation of the Need-Centered Watch-Assess-Need Intervention-Think Education and Training Program for Behavioral and Psychological Symptoms of Dementia

BACKGROUND

Despite the high prevalence of dementia among residents living in long-term care facilities in Taiwan, most care providers in these facilities have not received adequate training to deal with the behavioral and psychological symptoms of dementia (BPSD). An original care and management model for BPSD has been developed, and model-based recommendations for an education and training program have been made. However, empirical testing has not yet been conducted to determine the efficacy of this program.

PURPOSE

This study was designed to evaluate the feasibility of using the Watch-Assess-Need intervention-Think (WANT) education and training program for BPSD in long-term care settings.

METHODS

A mixed-method design was used. Twenty care providers and 20 corresponding care receivers (residents with dementia) from a nursing home in southern Taiwan were enrolled. Data were collected using a variety of measurement tools, including the Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia, Attitude towards Dementia Care Scale, and Dementia Behavior Disturbance Self-efficacy Scale. Qualitative data, including care-provider perspectives on the efficacy of the WANT education and training program, were also collected. Repeated measures were conducted on the results of quantitative data analysis, whereas content analysis was performed on the results of qualitative data analysis.

RESULTS

Findings indicate that the program relieves agitated behavior (p = .01), alleviates depression in those with dementia (p < .001), and enhances care-provider attitudes toward dementia care (p = .01). However, no significant improvement was found in self-efficacy among the care providers (p = .11). In terms of qualitative outcomes, care providers indicated they perceived improved self-efficacy in managing BPSD, improved ability to view problems from a more need-centered perspective, improved attitudes toward dementia and patients' BPSD, and decreased care burden and stress.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The study found the WANT education and training program to be feasible in clinical practice. Because of this program's simple and easy-to-remember characteristics, it is recommended that it be vigorously promoted to care providers in both long-term institutional and home care settings to help them effectively address the BPSD.

Attitudes and knowledge of nurses working at night and sleep promotion in nursing home residents: multicenter cross-sectional survey

BACKGROUND

Sleep disturbances are common in nursing home residents and challenging for their nurses. Knowledge about sleep and sleep promoting factors is essential to provide adequate sleep management, where nurses play a key role. Therefore, nurses' knowledge and attitudes towards sleep and sleep promoting interventions is important as enabling or inhibiting factor for successful sleep management.

METHODS

A multicenter cross-sectional study was conducted among nurses working wholly or partially at night in nursing homes in Germany. Data were collected between February and April 2021 via online or paper and pencil questionnaires, comprising 56 items. Nursing homes were recruited through existing cooperation with the study centers as well as via nursing home registers.

RESULTS

Finally, 138 nursing homes participated and 271 nurses completed the survey. Nurses agreed that sleep disturbances are an important topic with important impact on resident' health. Although, the assessment of sleep was seen as nurses' responsibility, only 40 nurses (14.7%) stated that residents' sleep was always documented. Only 21.7% reported the availability of policy documents providing guidance regarding the management of sleep disturbances. The vast majority (93.2%) reported never having received training about sleep and management of sleep disturbances after their basic nursing training.

CONCLUSIONS

Our results indicate that nurses working at night can play an important role in residents' sleep promotion. The findings indicate nurses' educational needs regarding sleep and sleep promotion. Nursing homes should implement institutional guidelines in order to promote residents' sleep based on adequate evidence-based non-pharmacological interventions.

Residential aged care staff perceptions and responses towards neuropsychiatric symptoms: a mixed methods analysis of electronic healthcare records

OBJECTIVES

To investigate electronic care notes to better understand reporting and management of neuropsychiatric symptoms (NPS) by residential aged care (RAC) staff.

METHODS

We examined semi-structured care notes from electronic healthcare notes of 77 residents (67% female; aged 67-101; 79% with formal dementia diagnosis) across three RAC facilities. As part of standard clinical practice, staff documented the NPS presentation and subsequent management amongst residents. Using a mixed-method approach, we analyzed the type of NPS reported and explored care staff responses to NPS using inductive thematic analysis.

RESULTS

465 electronic care notes were recorded during the 18-month period. Agitation-related behaviors were most frequently reported across residents (48.1%), while psychosis (15.6%), affective symptoms (14.3%), and apathy (1.3%) were less often reported. Only 27.5% of the notes contained information on potential causes underlying NPS. When faced with NPS, care staff responded by either providing emotional support, meeting resident's needs, removing identified triggers, or distracting.

CONCLUSION

Results suggest that RAC staff primarily detected and responded to those NPS they perceived as distressing. Findings highlight a potential under-recognition of specific NPS types, and lack of routine examination of NPS causes or systematic assessment and management of NPS. These observations are needed to inform the development and implementation of non-pharmacological interventions and care programs targeting NPS in RAC.

Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2022.2032597 .

Effectiveness of dementia education for professional care staff and factors influencing staff-related outcomes: An overview of systematic reviews

BACKGROUND

Care staff often lack knowledge, confidence, skills, and competency to provide optimal care for people with dementia. Dementia education can increase staff competency and wellbeing along with the actual care of people with dementia. Several factors can affect the effectiveness of dementia education; however, it is not yet established which factors are most important.

OBJECTIVE

The aim of the overview of systematic reviews is to investigate the effectiveness of dementia education for care staff on staff-related outcomes and influencing factors, identify needs for future research, and provide practical recommendations for effective dementia education.

METHODS

Systematic searches were conducted in PubMed, Cinahl, and PsycInfo accompanied by manual citation and reference searches. For inclusion, reviews must report on either effectiveness of one staff-related outcome or on factors influencing the effectiveness of dementia education for care staff. Quality assessments were conducted using AMSTAR2. After data extraction, results on effectiveness were structured according to satisfaction, learning, behavior, and results. Results on contributing factors to effectiveness were categorized into program, personal and organizational factors. All results were qualitatively summarized and reported according to the PRISMA statement.

RESULTS

Seventeen systematic reviews of low to medium quality were included. Dementia education positively affects knowledge, self-efficacy, and attitudes towards dementia and people with dementia. Care staff experienced improvements in communication and behavior management and reduction in behavioral symptoms of dementia of people with dementia was seen as well. Most reviews found no changes within restraints, medication, staff well-being and job satisfaction. Factors contributing to effectiveness are relevant and directly applicable content, active learning methods, classroom teaching combined with practical experience, theory-driven approaches and feedback sessions. Finally, the instructor needs to be experienced within dementia and sensitive to the needs of participants.

CONCLUSION

There is no one-size-fits-all in dementia education: however, perceived relevance and applicability are key elements for effective dementia education. Due to low quality of primary studies, further research of high methodological quality is needed on effectiveness of dementia education on staff behavior, wellbeing, and job satisfaction as well as on influencing factors and their impact on mechanisms of change.

A Systematic Review of the Effectiveness of Educational Interventions in Promoting Person-Centred Care in Dementia Services

OBJECTIVES

To review evidence about the effectiveness of educational programmes in promoting the delivery of person-centered care by staff in dementia services.

METHODS

Several databases were searched, and the methodological quality of identified studies systematically evaluated. A summary mean effect size was calculated for several types of outcome (direct knowledge, applied knowledge, attitudes, self-reported and observed working practices).

RESULTS

Eighteen studies were identified. Results were mixed, with findings of no change, significant improvement, and (in attitude) significant deterioration. Effect size was modest for direct knowledge (standardized mean difference = 0.6), but small or negligible for applied knowledge (0.29) and self-reported (0.06) and observed (0.25) working practices. There was a negative effect for attitudes (-0.17).

CONCLUSIONS

The quality of evidence was poor. Apart from attitudes, the effect sizes are likely to be overestimates. There was little evidence that education programmes can reliably produce substantial improvements in working practices.

CLINICAL IMPLICATIONS

Education alone is unlikely to be sufficient for establishing high standards of person-centered care in services. It needs to be supplemented by steps to ensure that staff develop skills in delivering such care in practice, and by organizational support to ensure staff have sufficient motivation, cues and opportunities for implementation.

Taking the 'care' out of care homes: The moral dilemma of institutional long-term care provision during COVID-19

Little is known on how the pandemic has changed care home care delivery. The aim of this study was to explore the impact of COVID-19 on care provision and visits in care homes from staff and family members' perspectives. For this purpose, we conducted a telephone- and zoom-based qualitative semi-structured interview study. Care home staff and family carers of people living with dementia (PLWD) across the UK were recruited via convenience sampling and participated via telephone or online. Participants took part in a semi-structured remote interview. Data were collected between October and November 2020. Anonymised transcripts were analysed separately by two research team members using thematic analysis, with codes discussed and themes generated jointly, supported by research team input. 42 participants (26 family carers and 16 care home staff) took part. Five themes were generated: (a) Care home reputation and financial implications; (b) Lack of care; (c) Communication or lack thereof; (d) Visiting rights/changes based on residents' needs; (e) Deterioration of residents. With a lack of clear guidance throughout the pandemic, care homes delivered care differently with disparities in the levels and types of visiting allowed for family members. Lack of communication between care homes and family members, but also government and care homes, led to family carers feeling excluded and concerned about the well-being of their relative. Improved communication and clear guidance for care homes and the public are required to negate the potentially damaging effects of COVID-19 restrictions upon residents, their families and the carers who support them.

Factors influencing the implementation of person-centred care in nursing homes by practice development champions: a qualitative process evaluation of a cluster-randomised controlled trial (EPCentCare) using Normalization Process Theory

Background

Person-centred care (PCC) has been suggested as the preferred model of dementia care in all settings. The EPCentCare study showed that an adapted PCC approach was difficult to implement and had no effect on prescription of antipsychotics in nursing home residents in Germany.

This paper reports the qualitative process evaluation to identify facilitators and barriers of the implementation of PCC in German nursing homes from the perspective of participating practice development champions.

Methods

Five individual and 14 group interviews were conducted with 66 participants (staff and managers) from 18 nursing homes. The analysis was based on inductive coding to identify factors influencing the PCC implementation process. Identified factors were systematised and structured by mapping them to the four constructs (coherence, cognitive participation, collective action, reflexive monitoring) of the Normalization Process Theory (NPT) as a framework that explains implementation processes.

Results

Facilitating implementation factors included among others broadening of the care perspective (coherence), tolerance development within the care team regarding challenging behaviour (cognitive participation), testing new approaches to solutions as a multi-professional team (collective action), and perception of effects of PCC measures (reflexive monitoring). Among the facilitating factors reported in all the NPT constructs, thus affecting the entire implementation process, were the involvement of relatives, multi-professional teamwork and effective collaboration with physicians.

Barriers implied uncertainties about the implementation and expectation of a higher workload (coherence), concerns about the feasibility of PCC implementation in terms of human resources (cognitive participation), lack of a person-centred attitude by colleagues or the institution (collective action), and doubts about the effects of PCC (reflexive monitoring). Barriers influencing the entire implementation process comprised insufficient time resources, lack of support, lack of involvement of the multi-professional team, and difficulties regarding communication with the attending physicians.

Conclusions

The findings provide a comprehensive and detailed overview of facilitators and barriers structured along the implementation process. Thus, our findings may assist both researchers and clinicians to develop and reflect more efficiently on PCC implementation processes in nursing homes.

Trial registration

ClinicalTrials.gov identifier: NCT02295462; November 20, 2014.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00963-6.

The characteristics of effective technology-enabled dementia education: a systematic review and mixed research synthesis

BACKGROUND

Dementia education is required to address gaps in dementia-specific knowledge among health and social care practitioners amidst increasing dementia prevalence. Harnessing technology for dementia education may remove obstacles to traditional education and empower large communities of learners. This systematic review aimed to establish the technological and pedagogical characteristics associated with effective technology-enabled dementia education for health and social care practitioners.

METHODS

MEDLINE, PubMed, Web of Science, CINAHL, Scopus, PsycINFO, ERIC and OVID Nursing Database were searched from January 2005 until February 2020. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Study quality was assessed with the Mixed Methods Appraisal Tool. Quantitative evidence was categorised based on Kirkpatrick's Model. Qualitative data was synthesised thematically and integrated with quantitative findings before conclusions were drawn.

RESULTS

Twenty-one published papers were identified. Participants were acute, primary and long-term care practitioners, or were students in higher education. Most training was internet-based; CD-ROMs, simulations and tele-mentoring were also described. Technology-enabled dementia education was predominantly associated with positive effects on learning outcomes. Case-based instruction was the most frequently described instructional strategy and videos were common modes of information delivery. Qualitative themes emerged as existing strengths and experience; knowledge gaps and uncertainty; developing core competence and expertise; involving relevant others; and optimising feasibility.

DISCUSSION

Technology-enabled dementia education is likely to improve dementia knowledge, skills and attitudes among health and social care practitioners from multiple practice contexts. Confidence in the results from quantitative studies was undermined by multiple confounding factors that may be difficult to control in the educational research context. Convenience and flexibility are key benefits of technology-enabled instructive and simulated pedagogy that can support the application of theory into practice. More research is required to understand the role of online learning networks and provisions for equitable engagement. A future emphasis on organisational and environmental factors may elucidate the role of technology in ameliorating obstacles to traditional dementia education.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ( CRD42018115378 ).

An Innovative Framework for Sustainable Development in Healthcare: The Human Rights Assessment

Healthcare providers are investing considerable resources for the development of quality management systems in hospitals. Contrary to these efforts, the number of tools that allow the evaluation of implementation efforts and the results of quality, security and sustainable development is quite limited. The purpose of the study is to develop a reference framework for quality and sustainable development in healthcare, Sanitary-Quality (San-Q) at the micro system level, which is compatible with applicable national and international standards in the field. The research method consisted of the study of literature, identification and analysis of good sustainability practices in healthcare, which allowed identification of the areas of the new San-Q framework: quality, economic, environmental, social, institutional and healthcare. These areas are incorporated into the core topics of social responsibility mentioned by ISO26000. A total of 57 indicators have been defined that make up the new reference framework. The evaluation format of the indicators is innovative through a couple of values: completion degree–significance. In the experimental part of the research, a pilot implementation of the San-Q framework at an emergency hospital was performed, the results recorded in terms of responsibility for human rights being presented. The conclusions of the study reveal the innovative aspects of the framework that facilitate the development of a sustainability strategy promoted through performance indicators, the results obtained after evaluation being useful in establishing a reference level of sustainability but also in developing sustainability policies.

Development and palliative care staff reactions to a sleep regulation educational intervention

Background

In palliative care, sleep and circadian rhythm problems are common symptoms. Nonpharmacological interventions are available; however, health care providers are not aware of these or lack the knowledge to effectively implement in practice. This study reports the content and design development of the PRIME™ (Program for Improving & Managing Environments for Sleep) sleep online educational intervention as well as the evaluation of the intervention by practicing nurses with a focus on perceived acceptability and satisfaction.

Methods

Development of the education employed a multi-step process that assesses the current state of the science in this area (literature reviews), the needs of regional target recipients (hospice/palliative care staff), expert recommendations and views of a national pool of hospice/palliative workers. A cross-sectional, descriptive study with key staff informants evaluated the acceptability and usability of the modules using both scale-response items to rate the content and design of the modules and overall satisfaction and five open-response questions to suggest changes to the educational intervention.

Results

Among 31 palliative care professionals, most rated the content and design favorably. A total of 20 participants provided suggestions to improve the educational intervention. Their comments were categorized into six themes: Integration into Practice; Content, Exercises and Material Provided by Modules; User Interface and Design; and Adapt and Expand Modules for Public, Family and Caregivers.

Conclusions

The data suggest that the PRIME™ educational intervention can be an effective tool to train direct-care palliative care professionals on interventions for use in their daily practice. We also demonstrated that the educational intervention is feasible to deliver online and that the online modules appealed to respondents, suggesting that future delivery of the educational intervention can use the same or similar modes of presentation.

Communication training programmes for informal caregivers of people living with dementia: A systematic review

AIMS AND OBJECTIVES

Current research suggests that communication training programmes for caregivers of people living with dementia can benefit both parties by improving communication, quality of life and stress. Previous reviews in this area focus on mixed samples of formal and informal caregivers. This review aimed to evaluate current research for trainings specifically for informal caregivers, including the research quality and the key training components.

DESIGN AND METHODS

The review followed the PRISMA research reporting checklist. The electronic databases CINAHL, Embase, Medline and Psychinfo and reference lists of included literature were searched for studies relevant to the aims. Of the 45 identified studies, 36 were excluded based on pre-specified criteria. Nine studies were included in the final review and subject to quality appraisal using the Qualsyst tool.

RESULTS

The included studies' programmes averaged 5 to 6 hours in length over four to five sessions, were mostly face to face in both group and individual settings and were developed using various communication and psychological theories. Studies demonstrated variable quality and outcomes, making it difficult to identify optimal components. However, careful consideration of different factors enabled some suggestions for training dose, delivery method, content and outcomes to measure.

CONCLUSIONS

Communication training programmes can benefit people living with dementia and their informal caregivers in outcomes such as communication skills and quality of life. Suggestions are made on the training components that optimise these benefits.

RELEVANCE TO CLINICAL PRACTICE

Given the clear benefits on outcomes such as quality of life, there is a need for communication trainings to be offered in clinical contexts. However, given the limited pool of variable quality research and lack of accessible manuals, it is unlikely that this is the case. Consolidating and widening the evidence through further research is essential in making these trainings more widely available.

Aged care staff perceptions of an online training program for responsive behaviours of residents with dementia

OBJECTIVE

To explore residential aged care staff perceptions of an online training program on the management of antipsychotic medications for responsive behaviour in residential aged care.

METHODS

A qualitative process evaluation was undertaken in four residential aged care facilities of one organisation in Australia. Five focus group interviews were conducted with 25 participants including nurses, care workers, occupational therapists and assistants.

RESULTS

Direct care staff found that the training program increased their awareness and knowledge of responsive behaviours associated with dementia. Inductive thematic analysis identified three themes: (1) impact of online learning for dementia care; (2) applying online learning in dementia practice; and (3) realising the benefits and challenges of online learning.

CONCLUSION

From the perspective of the participants, the online training program had a positive effect on their knowledge, communication and practice of caring for residents with dementia with responsive behaviours.

Multicomponent Staff Training Intervention to Improve Residential Dementia Care (PROCUIDA-Demencia): A Mixed-Methods 2-Arm Cluster Randomized Controlled Pilot and Clinical Outcomes Study

OBJECTIVES

To evaluate the feasibility outcomes of implementing a multicomponent staff training intervention (PROCUIDA-Demencia) to promote psychosocial interventions and reduce antipsychotic prescription in Mexican care homes and study its effect on staff's care experience and residents' quality of life.

DESIGN

A mixed-methods 2-arm cluster randomized controlled pilot study of a 2-day staff training program with baseline, 12 weeks, and 24 weeks of the PROCUIDA-Demencia intervention vs treatment as usual (TAU).

SETTING AND PARTICIPANTS

Eight care homes in Mexico City were selected, from which 55 residents and 126 staff were recruited.

INTERVENTION

In situ staff training consisting of evidence-based manualized psychosocial interventions of person-centered activities, reminiscence therapy, doll therapy, psychomotor dance therapy, and antipsychotic prescription review. Fidelity to protocol was supervised once a week.

METHODS

Cluster-level feasibility measures included views of staff, residents, and relatives on acceptability, satisfaction, adherence, and fidelity to the intervention. Staff outcome measures were Maslach Burnout Inventory (MBI), Approaches to Dementia Questionnaire, and Sense of Competence in Dementia Care Staff. Residents' outcome measures included Quality of Life-Alzheimer's Disease scale (QoL-AD), and Neuropsychiatric Inventory-Nursing Home Version (NPI-NH). Staff distress was measured using the NPI-NH occupational disturbance scale. Feasibility was elicited through a focus group, and hierarchical linear mixed effects models were used to assess the adjusted effects of the respective measures.

RESULTS

Observed medical practice showed the prescription of at least 1 antipsychotic in 41% of participants in the intervention group. Overall, 39% of residents reported discontinuation, and 15% reduction of antipsychotics, following the 12-week medical review in parallel with psychosocial interventions. Clinical outcomes contributed positively to the reduction in baseline staff burden according to the MBI after the intervention [mean difference -8.9, 95% confidence interval (CI) -17.7, -0.1, P = .049] and to the reduction in severity and frequency of behavior as per NPI-NH in residents (mean difference -9.4, 95% CI -17.5, -1.3, P = .025).

CONCLUSIONS AND IMPLICATIONS

PROCUIDA-Demencia is a feasible intervention for Mexican care homes. Results contribute to the Mexican Dementia Plan optimizing dementia care by supporting the need for staff training to implement psychosocial interventions prior to prescribing antipsychotic medication.

Evaluation and Effectiveness of Dementia Staff Training Programs in General Hospital Settings: A Narrative Synthesis with Holton's Three-Level Model Applied

Background:

People with Dementia (PwD) are frequently admitted to hospital settings. The lack of proper dementia knowledge, poor communication skills, negative attitudes toward dementia, and lack of confidence affects the quality of care, thus development of dementia trainings has increased. Nevertheless, literature regarding the effectiveness of training implementation is limited.

Objective:

The aim of this narrative synthesis is to 1) identify the characteristics of training programs and 2) explore the effectiveness of these training programs in everyday clinical practice.

Methods:

A systematic search in PubMed, PsycINFO, CINAHL, and Cochrane was conducted, including qualitative and quantitative peer-reviewed studies. Holton’s evaluation model with its three outcome levels (learning, individual performance, and organizational results) was adopted. 14 studies were included.

Results:

The synthesis of the results was divided into two parts: 1) to describe the characteristics and content of trainings 2) to evaluate the effectiveness of training programs according to the three outcome levels of Holton’s model, taking into consideration its construct domains: ability, motivation, and environment. Learning outcomes were assessed in all selected studies: 13 studies observed changes in individual performance, four studies reported changes within the organizational level, and only five showed sustainable changes over time.

Conclusion:

Person-centered care (PCC) approaches, interactive and varied teaching methods, supporting conditions like champions, action plans, and setting care policies, are all characteristics of effective trainings. Successful programs should be sustainable over time, demonstrating positive outcomes across the organization. Based on current findings, there is a lack of adequate evaluation with regard to training programs on the organizational level.

Key Intervention Categories to Provide Person-Centered Dementia Care: A Systematic Review of Person-Centered Interventions

Background:

Person-centered care (PCC) is an important concept in many countries’ national guidelines and dementia plans. Key intervention categories, i.e., a taxonomy of person-centered (PC)-interventions, to provide person-centered dementia care, are difficult to identify from literature.

Objective:

This systematic review aimed to identify and categorize published PC-interventions into key intervention categories to guide the provision of person-centered dementia care.

Methods:

Conduct of this systematic review followed Cochrane guidelines. A search of the dimensions ‘Dementia’, ‘Person-Centered Care’, and ‘Intervention’ combined was performed in PubMed, EMBASE, and Web of Science. Study selection was based on 2-stage screening against eligibility criteria, limited to controlled study designs. Information about interventions and outcomes was extracted into an “Effects Table”. The identified PC-interventions were categorized in intervention categories to provide person-centered dementia care.

Results:

Searches identified 1,806 records. 19 studies were included. These covered a range of psychosocial interventions, oftentimes multi-component interventions, which followed heterogeneous approaches. Studies were conducted in long-term care/hospital settings. Nine key intervention categories were identified: social contact, physical activities, cognitive training, sensory enhancement, daily living assistance, life history oriented emotional support, training and support for professional caregivers, environmental adjustments, and care organization.

Conclusion:

Our findings provide a current overview of published PC-interventions in dementia, which followed heterogeneous approaches under the PCC-concept. The heterogeneity made it challenging to identify a well-defined concept of PCC and common key intervention categories. An effectiveness-evaluation of “PC” - including “relationship-centered”-interventions may be valuable, to assess whether an explicit focus on relationships around PCC-interventions yields an added benefit.

PROSPERO-ID: CRD42021225084.

Long-term implementation of the Managing Agitation and Raising QUality of lifE intervention in care homes: A qualitative study

OBJECTIVES

The dementia care home workforce receives little specific training. There are successful interventions, improving care outcomes, but it is unclear whether or how to sustain these effects. The Managing Agitation and Raising Quality of Life (MARQUE) intervention aimed to train care home staff to reduce resident agitation and improve quality of life. It was designed for sustainability, with implementation plans agreed with managers. MARQUE improves quality of life. In this separate study, we aimed to examine implementation around 2 years later.

METHODS AND DESIGN

We explored practice change since the intervention and considered current implementation of home-specific action plans, enablers or barriers, and perceived benefits or harms of implementation using semi-structured interviews with staff working in the trial homes who received the MARQUE intervention.

RESULTS

Six out of 10 intervention homes participated. We interviewed 25 staff, 20-30 months after the MARQUE study. In all homes, staff reported that at least one MARQUE component was sustained. Three themes emerged about sustained practice change: (i) communication, (ii) respect and understanding of roles, and (iii) ability to try new things. Notable changes included improved team working and feelings of competence, positive attitude to residents rather than blame for agitation and avoidance, and more pleasant activities. Leadership support was important.

CONCLUSIONS

It is possible to sustain some change over years in care homes. This study indicates factors which help or impede. These factors individually and together could lead to long-term improved quality of life of residents in homes where it is implemented and sustained.

A predictive model of the perceptions of patient-centered care among nurses in long-term care hospitals: A cross-sectional study

This study aimed to propose and examine a predictive model of the impacts of organizational and individual factors on the perceptions of patient-centered care (PCC) among nurses working in long-term care hospitals. A cross-sectional study was conducted at six hospitals in South Korea. Data collected from 187 nurses were analyzed using structural equation modeling. Findings showed that the model explained the impacts of the factors on how nurses perceive PCC, it explaining 47% of the variation in PCC. Organizational factors had stronger influences on PCC [innovative organizational culture (β = 0.34), teamwork (β = 0.30)] compared to individual factors [compassion (β = 0.15), self-leadership (β = 0.07)]. The hypothesized model has potential for determining the factors that influence the perceptions of PCC among nurses working in long-term care hospitals. Further strategies should focus on organizational factors in strategies for improving long-term care nurses' perceptions of PCC.

Paradoxes of person-centred care: A discussion paper

Aim

Previous research has mainly focused on the advantages of PCC and less on its disadvantages. Hence, there is a need to further explore the recent research regarding PCC from both sides. Therefore, the aim of this paper is to elucidate the advantages and disadvantages of PCC.

Design

Discussion paper.

Methods

We searched relevant literature published January 2000-March 2018 in PubMed, Medline, CHINAL, Scopus and Web of Science.

Results

The results showed that PCC can contribute to improved health and well-being, improved mutual interaction in relationships, improved cost-effectiveness and improved work environment, while the disadvantages can involve increased personal and financial costs, exclusion of certain groups, increased personal and financial costs, exclusion of staff's personhood and unfairness due to empathy. An analysis of the existing literature on PCC showed paradoxes, which call for further investigation.

Effects of a person-centred and thriving-promoting intervention on nursing home staff job satisfaction: A multi-centre, non-equivalent controlled before-after study

Aim

To evaluate the effects of a person‐centred and thriving‐promoting intervention in nursing homes on staff job satisfaction, stress of conscience and the person‐centredness of care and of the environment.

Design

A multi‐centre, non‐equivalent control group, before–after trial design.

Methods

Staff (N = 341) from six nursing homes in Australia, Norway and Sweden were assigned to the intervention or the control group and both groups were evaluated before the intervention, immediately after and by 6 months follow‐up. Staff completed a questionnaire about job satisfaction (primary endpoint), stress of conscience and the person‐centredness of care and of the environment (secondary endpoints). Linear regression models were used to identify the mean scores and to analyse group differences to test the effects of the intervention.

Results

The intervention had no statistically significant effects on staff job satisfaction, level of stress of conscience or the perceived person‐centredness of care and of the environment.

Improving mental health and reducing antipsychotic use in people with dementia in care homes: the WHELD research programme including two RCTs

Background

The effective management of agitation and other neuropsychiatric and behavioural symptoms in people with dementia is a major challenge, particularly in care home settings, where dementia severity is higher and there is limited training and support for care staff. There is evidence for the value of staff training and the use of psychosocial approaches; however, no intervention currently exists that combines these elements into an intervention that is fit for purpose and effective in these settings based on evidence from a randomised controlled trial.

Objective

The objective was to develop and evaluate a complex intervention to improve well-being, reduce antipsychotic use and improve quality of life in people with dementia in care homes through person-centred care, management of agitation and non-drug approaches.

Design

This was a 5-year programme that consisted of six work packages. Work package 1 consisted of two systematic reviews of personalised psychosocial interventions for behavioural and psychological symptoms for people with dementia in care homes. Work package 2 consisted of a metasynthesis of studies examining implementation of psychosocial interventions, in addition to developing a draft Well-being and Health for people with Dementia (WHELD) programme. Work package 3 consisted of a factorial study of elements of the draft WHELD programme in 16 care homes. Work package 4 involved optimisation of the WHELD programme based on work package 3 data. Work package 5 involved a multicentre randomised controlled trial in 69 care homes, which evaluated the impact of the optimised WHELD programme on quality of life, agitation and overall neuropsychiatric symptoms in people with dementia. Work package 6 focused on dissemination of the programme.

Setting

This programme was carried out in care homes in the UK.

Participants

Participants of this programme were people with dementia living in care homes, and the health and care professionals providing treatment and care in these settings.

Results

Work package 1: reviews identified randomised controlled trials and qualitative evidence supporting the use of psychosocial approaches to manage behavioural symptoms, but highlighted a concerning lack of evidence-based training manuals in current use. Work package 2: the meta-analysis identified key issues in promoting the use of interventions in care homes. The WHELD programme was developed through adaptation of published approaches. Work package 3: the factorial trial showed that antipsychotic review alone significantly reduced antipsychotic use by 50% (odds ratio 0.17, 95% confidence interval 0.05 to 0.60). Antipsychotic review plus social interaction significantly reduced mortality (odds ratio 0.36, 95% confidence interval 0.23 to 0.57), but this group showed significantly worse outcomes in behavioural and psychological symptoms of dementia than the group receiving neither antipsychotic review nor social interaction (mean difference 7.37 symptoms, 95% confidence interval 1.53 to 13.22 symptoms). This detrimental impact was reduced when combined with social interaction (mean difference –0.44 points, 95% confidence interval –4.39 to 3.52 points), but with no significant benefits for agitation. The exercise intervention significantly improved neuropsychiatric symptoms (mean difference –3.58 symptoms, 95% confidence interval –7.08 to –0.09 symptoms) but not depression (mean difference –1.21 points, 95% confidence interval –4.35 to 1.93 points). Qualitative work with care staff provided additional insights into the acceptability and feasibility of the intervention. Work package 4: optimisation of the WHELD programme led to a final version that combined person-centred care training with social interaction and pleasant activities. The intervention was adapted for delivery through a ‘champion’ model. Work package 5: a large-scale, multicentre randomised controlled trial in 69 care homes showed significant benefit to quality of life, agitation and overall neuropsychiatric symptoms, at reduced overall cost compared with treatment as usual. The intervention conferred a statistically significant improvement in quality of life (Dementia Quality of Life Scale – Proxy z-score of 2.82, mean difference 2.54, standard error of measurement 0.88, 95% confidence interval 0.81 to 4.28, Cohen’s d effect size of 0.24; p = 0.0042). There were also statistically significant benefits in agitation (Cohen-Mansfield Agitation Inventory z-score of 2.68, mean difference –4.27, standard error of measurement 1.59, 95% confidence interval –7.39 to –1.15, Cohen’s d effect size of 0.23; p = 0.0076) and overall neuropsychiatric symptoms (Neuropsychiatric Inventory – Nursing Home version z-score of 3.52, mean difference –4.55, standard error of measurement 1.28, 95% confidence interval –7.07 to –2.02, Cohen’s d of 0.30; p < 0.001). The WHELD programme contributed to significantly lower health and social care costs than treatment as usual (cost difference –£4740, 95% confidence interval –£6129 to –£3156). Focus groups were conducted with 47 staff up to 12 months after the end of work package 5, which demonstrated sustained benefits. Work package 6: the outputs of the programme were translated into general practitioner workshops and a British Medical Journal e-learning module, an updated national best practice guideline and a portfolio of lay and care home outreach activities.

Limitations

Residents with dementia were not involved in the qualitative work.

Conclusions

The WHELD programme is effective in improving quality of life and reducing both agitation and overall neuropsychiatric symptoms in people with dementia in care homes. It provides a structured training and support intervention for care staff, with lower overall costs for resident care than treatment as usual.

Future work

It will be important to consider the long-term sustainability of the WHELD programme and cost-effective means of long-term implementation.

Trial registration

Current Controlled Trials ISRCTN40313497 and ISRCTN62237498.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 6. See the NIHR Journals Library website for further project information.

The impact of person-centred care on patient safety: An umbrella review of systematic reviews

BACKGROUND

Nursing literature frequently emphasises the benefits of person-centred approaches for healthcare quality and safety.

OBJECTIVE

This umbrella review aimed to synthesise the combined evidence from systematic reviews assessing the impact of person-centred care interventions on patient safety.

DESIGN

A three-step review process included a preliminary review of literature, a comprehensive search, and manual searching of reference lists and forward citations of selected reviews. The review protocol was registered with Prospero (CRD42018090048).

DATA SOURCES

Reviewers searched 10 databases for systematic reviews published in English-language peer-reviewed journals between 2000 and 2019: Academic Search Complete, CINAHL, Cochrane Library, EMBASE, JBI Database, Medline, ProQuest Health & Medicine, PROSPERO Register, PubMed and Scopus.

REVIEW METHODS

Covidence software was used to manage screening and eligibility. Two reviewers independently screened titles and abstracts, reviewed full texts of articles for eligibility, and appraised the quality of reviews using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses.

RESULTS

From an initial total of 3412 potential titles, 16 reviews met the inclusion criteria. The selected reviews examined the impact of person-centred care for diverse groups of patients (children, adults and older people) in varied settings. Most systematic reviews assessed experimental studies, generally comparing person-centred interventions with 'usual care', often demonstrating limited evidence of impact on safety. Reviews addressed several patient safety outcomes relevant to nursing, including falls, infections, medication use and misuse, and mortality rates. The systematic reviews were generally well conducted, although several included studies of poor or fair quality. Given the heterogeneity of the interventions, outcomes and research designs of studies included in the selected reviews, we were unable to draw unequivocal conclusions about the implications of person-centred care for patient safety in this umbrella review. However, there was some encouraging evidence that person-centred care initiatives may result in reduced rates of falls (in acute care and residential aged care settings). The review also highlighted reductions in agitation for people with dementia and some improvement in anti-psychotic medication use in older people with dementia.

CONCLUSIONS

Although abundant evidence exists demonstrating the positive effects of person-centred care on healthcare quality and on patient (and provider) wellbeing, there is little research focussing specifically on the impact of person-centred care on patient safety. Thus, there is scope for further high-quality nursing research into how person-centred interventions improve specific patient safety outcomes in order to inform more widespread adoption of person-centred practice.

Preference Consistency: Veteran and Non-Veteran Nursing Home Resident Self-Reported Preferences for Everyday Living

Understanding patient preferences is core to person-centered care. The consistency of everyday preference reporting was assessed comparing responses of Veteran (VA) and non-VA nursing home (NH) residents on the Preferences for Everyday Living Inventory (PELI) at baseline and 5 to 7 days later. Non-VA NH residents demonstrated higher perfect agreement than VA residents (66% vs. 56%, respectively) and higher acceptable agreement (95% vs. 88%, respectively). Multiple regression analyses examined significant predictors of reliability using demographics, cognitive functional variables, and interviewer ratings. In the VA group, higher perfect agreement was associated with residents who were less likely to have hearing deficits, better cognition, and better interviewer ratings related to energy, attention, and comprehension. In the non-VA group, higher perfect agreement was associated with residents who were younger and more independent with walking. Overall, higher agreement was associated with being female, non-VA, and having better cognition. Implications for future research and clinical practice are highlighted. [Journal of Gerontological Nursing, 46(3), 15-25.].

<p>A Scoping Review and Template Analysis of Manual-Based Complex Interventions in Dementia Care</p>

Purpose

In dementia care, the complexity of psychosocial needs and contextual variables often demands nonpharmacological interventions of a complex nature. The purpose of this scoping review was to investigate (1) how manuals published in refereed journals explaining procedures of complex interventions in dementia care are structured and their content disseminated and (2) to provide recommendations for future manuals.

Methods

A systematic search was conducted using four databases (Embase, PsychInfo, CINAHL and Scopus) following PRISMA-ScR and PICo method. The results were analysed using template analysis aiming to describe the possibility of tailoring the intervention, degree of flexibility of the manual and dissemination elements used in the manual.

Results

A total of 882 records were identified, and 86 full-text articles were assessed. Nine articles containing manuals met the inclusion criteria. All of the included manuals allowed the user to tailor actions in the intervention to specific situations. Two-thirds of the manuals showed a medium degree of flexibility. The types of dissemination elements varied. All used written text, and some used various graphical organisers such as headlines and lists. None used illustrations or audio/video material.

Conclusion

Currently, only few manuals for complex interventions in the field of dementia are published in refereed journals, all disseminated as written text. For future manuals, we suggest considering the inclusion of illustrations and/or audio/video material to describe actions, to allow for tailoring of the intervention, and to maintain a medium or low degree of flexibility by structuring the content hierarchically in phases while providing the user with detailed description of what to do, and how to decide what to.

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Dementia Care Mapping™ to reduce agitation in care home residents with dementia: the EPIC cluster RCT

BACKGROUND

The quality of care for people with dementia in care homes is of concern. Interventions that can improve care outcomes are required.

OBJECTIVE

To investigate the clinical effectiveness and cost-effectiveness of Dementia Care Mapping™ (DCM) for reducing agitation and improving care outcomes for people living with dementia in care homes, versus usual care.

DESIGN

A pragmatic, cluster randomised controlled trial with an open-cohort design, follow-up at 6 and 16 months, integrated cost-effectiveness analysis and process evaluation. Clusters were not blinded to allocation. The primary end point was completed by staff proxy and independent assessors.

SETTING

Stratified randomisation of 50 care homes to the intervention and control groups on a 3 : 2 ratio by type, size, staff exposure to dementia training and recruiting hub.

PARTICIPANTS

Fifty care homes were randomised (intervention, n = 31; control, n = 19), with 726 residents recruited at baseline and a further 261 recruited after 16 months. Care homes were eligible if they recruited a minimum of 10 residents, were not subject to improvement notices, had not used DCM in the previous 18 months and were not participating in conflicting research. Residents were eligible if they lived there permanently, had a formal diagnosis of dementia or a score of 4+ on the Functional Assessment Staging Test of Alzheimer's Disease, were proficient in English and were not terminally ill or permanently cared for in bed. All homes were audited on the delivery of dementia and person-centred care awareness training. Those not reaching a minimum standard were provided training ahead of randomisation. Eighteen homes took part in the process evaluation.

INTERVENTION

Two staff members from each intervention home were trained to use DCM and were asked to carry out three DCM cycles; the first was supported by an external expert.

MAIN OUTCOME MEASURES

The primary outcome was agitation (Cohen-Mansfield Agitation Inventory), measured at 16 months. Secondary outcomes included resident behaviours and quality of life.

RESULTS

There were 675 residents in the final analysis (intervention, n = 388; control, n = 287). There was no evidence of a difference in agitation levels between the treatment arms. The adjusted mean difference in Cohen-Mansfield Agitation Inventory score was -2.11 points, being lower in the intervention group than in the control (95% confidence interval -4.66 to 0.44; p = 0.104; adjusted intracluster correlation coefficient: control = 0, intervention = 0.001). The sensitivity analyses results supported the primary analysis. No differences were detected in any of the secondary outcomes. The health economic analyses indicated that DCM was not cost-effective. Intervention adherence was problematic; only 26% of homes completed more than their first DCM cycle. Impacts, barriers to and facilitators of DCM implementation were identified.

LIMITATIONS

The primary completion of resident outcomes was by staff proxy, owing to self-report difficulties for residents with advanced dementia. Clusters were not blinded to allocation, although supportive analyses suggested that any reporting bias was not clinically important.

CONCLUSIONS

There was no benefit of DCM over control for any outcomes. The implementation of DCM by care home staff was suboptimal compared with the protocol in the majority of homes.

FUTURE WORK

Alternative models of DCM implementation should be considered that do not rely solely on leadership by care home staff.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN82288852.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 16. See the NIHR Journals Library website for further project information.

Developing evidence-based guidance for assessment of suspected infections in care home residents

BACKGROUND

The aim of this study was to update and refine an algorithm, originally developed in Canada, to assist care home staff to manage residents with suspected infection in the United Kingdom care home setting. The infections of interest were urinary tract infections, respiratory tract infections and skin and soft tissue infection.

METHOD

We used a multi-faceted process involving a literature review, consensus meeting [nominal group technique involving general practitioners (GPs) and specialists in geriatric medicine and clinical microbiology], focus groups (care home staff and resident family members) and interviews (GPs), alongside continual iterative internal review and analysis within the research team.

RESULTS

Six publications were identified in the literature which met inclusion criteria. These were used to update the algorithm which was presented to a consensus meeting (four participants all with a medical background) which discussed and agreed to inclusion of signs and symptoms, and the algorithm format. Focus groups and interview participants could see the value in the algorithm, and staff often reported that it reflected their usual practice. There were also interesting contrasts between evidence and usual practice informed by experience. Through continual iterative review and analysis, the final algorithm was finally presented in a format which described management of the three infections in terms of initial assessment of the resident, observation of the resident and action by the care home staff.

CONCLUSIONS

This study has resulted in an updated algorithm targeting key infections in care home residents which should be considered for implementation into everyday practice.

[Improving cognitive resources of nursing home residents: a systematic review of prevention and health promotion interventions]

BACKGROUND

The German Prevention Act mandated long-term care insurance funds to support long-term care facilities in designing health-promoting structures. One area of action is the promotion of the cognitive resources of nursing home residents. The objective of this systematic review was to describe and analyze interventions and intervention components that improve cognitive resources of nursing home residents.

METHODS

First, we conducted a search for systematic reviews to identify relevant randomised controlled trials in Medline via PubMed, the Cochrane Library, CINAHL, Gerolit, Embase, Psyndex, and Livivo; additional sources were hand-searched. Second, references of all relevant randomized controlled trials (n=43) were extracted from the identified systematic reviews (n=26). The original articles of the primary studies included were then considered and data extracted using criteria for the evaluation of complex interventions. The quality of evidence was assessed using the GRADE approach.

RESULTS

Nine interventions to promote cognitive resources were identified: cognitive stimulation, cognitive training, physical training, art and music interventions, bright light, multicomponent stimulation, multisensory stimulation, care staff training and reminiscence. The quality of the underlying evidence in the inpatient long-term care setting was predominantly low, therefore, it was not always possible to draw clear conclusions regarding the efficacy of the interventions. The low quality of evidence was mainly due to the high heterogeneity as well as the low number and limited methodological quality of the primary studies.

CONCLUSION

In general, a wide range of nonpharmacological interventions were reported. Due to the limited evidence, however, these may be regarded as ideas only or possible options for promoting the cognitive resources of nursing home residents.

A multifaceted intervention to reduce antimicrobial prescribing in care homes: a non-randomised feasibility study and process evaluation

Background

The most frequent acute health-care intervention that care home residents receive is the prescribing of medications. There are serious concerns about prescribing generally, and about antimicrobial prescribing in particular, with facilities such as care homes being described as an important ‘reservoir’ of antimicrobial resistance.

Objectives

To evaluate the feasibility and acceptability of a multifaceted intervention on the prescribing of antimicrobials for the treatment of infections.

Design

This was a non-randomised feasibility study, using a mixed-methods design with normalization process theory as the underpinning theoretical framework and consisting of a number of interlinked strands: (1) recruitment of care homes; (2) adaptation of a Canadian intervention (a decision-making algorithm and an associated training programme) for implementation in UK care homes through rapid reviews of the literature, focus groups/interviews with care home staff, family members of residents and general practitioners (GPs), a consensus group with health-care professionals and development of a training programme; (3) implementation of the intervention; (4) a process evaluation consisting of observations of practice and focus groups with staff post implementation; and (5) a survey of a sample of care homes to ascertain interest in a larger study.

Setting

Six care homes – three in Northern Ireland and three in the West Midlands.

Participants

Care home staff, GPs associated with the care homes and family members of residents.

Interventions

A training programme for care home staff in the use of the decision-making algorithm, and implementation of the decision-making algorithm over a 6-month period in the six participating care homes. REACH (REduce Antimicrobial prescribing in Care Homes) Champions were appointed in each care home to support intervention implementation and the training of staff.

Main outcome measures

The acceptability of the intervention in terms of recruitment, delivery of training, feasibility of data collection from a variety of sources, implementation, practicality of use and the feasibility of measuring the appropriateness of prescribing.

Results

Six care homes from two jurisdictions were recruited, and the intervention was adapted and implemented. The intervention appeared to be broadly acceptable and was implemented largely as intended, although staff were concerned about the workload associated with study documentation. It was feasible to collect data from community pharmacies and care homes, but hospitalisation data from administrative sources could not be obtained. The survey indicated that there was interest in participating in a larger study.

Conclusions

The adapted and implemented intervention was largely acceptable to care home staff. Approaches to minimising the data-collection burden on staff will be examined, together with access to a range of data sources, with a view to conducting a larger randomised study.

Trial registration

Current Controlled Trials ISRCTN10441831.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 8. See the NIHR Journals Library website for further project information. Queen’s University Belfast acted as sponsor.

"We should see her like part of the team": an investigation into care home staff's experiences of being part of an RCT of a complex psychosocial intervention

Objectives: To contribute to improvements in the design and delivery of intervention research in care homes by adopting a collaborative approach that listens to the experiences of care home staff who had participated in a clinical trial aimed at optimising and evaluating a psychosocial intervention package for people with dementia.Methods: Qualitative study involving focus group discussions (FGDs) involving 41 staff across 6 care homes with the UK. Inductive thematic analysis was used to identify themes and interpret the data.Results: Three overarching themes emerged as influential: Recognising preparedness; working together and learning more than expected. The findings highlighted the need to be attentive in addressing staff expectations, the value of sustained relationships and recognition of good practice. The FGDs also identified areas of unanticipated learning that staff and managers adopted.Conclusions: The FGDs showed the importance of considering the overall experience of care home staff who are involved in research and the importance of valuing the skills and experience they hold through positive affirmation. There are often unanticipated consequences of research involvement both on staff practice and on relationships which if promoted could help sustain effective ways of working together.

A systematic review of the impact of person-centred care interventions on the behaviour of staff working in dementia care

AIM

To examine the content, focus, and effectiveness of person-centred care (PCC) interventions aimed at increasing staff PCC behaviour in health and social care settings for people with dementia.

DESIGN

Systematic search and narrative synthesis of quantitative data.

DATA SOURCES

PsychINFO, Medline, EMBASE, Web of knowledge, CINAHL, ASSIA, and BNI were searched from inception to 5 November 2016.

REVIEW METHODS

All records retrieved were screened using predetermined eligibility criteria. Quality assessment was performed with the Effective Public Health Practice Project tool (EPHPP).

RESULTS

A total of 4,367 records were screened and 33 studies examining the impact of PCC interventions were included. Eight different categories of PCC intervention were identified, with seven of these having at least some evidence to support their effectiveness in increasing staff PCC behaviour.

CONCLUSION

The range of interventions and outcome measures identified in this review highlight different ways PCC behaviour can be demonstrated by staff and the range of interventions that can be used to enhance PCC staff behaviour. In future, more rigorously controlled research comparing the relative effectiveness of these interventions will support nursing facilities and staff to choose appropriate interventions to support them in enhancing PCC.

IMPACT

This study addressed the health priority of increasing PCC for people with dementia. It found preliminary evidence that seven of the eight intervention types identified are effective at increasing staff PCC behaviour in health and social care settings for people with dementia.

[Improving psychosocial health of nursing home residents: a systematic review of interventions for prevention and health promotion]

BACKGROUND

Long-term care insurance funds have been mandated by the German Prevention Act to support long-term care facilities in the implementation of health-promoting structures. One area of action is the promotion of the nursing home residents' psychosocial health. The objective of this systematic review was to describe and analyze interventions and intervention components related to the psychosocial health of nursing home residents.

METHODS

First, we conducted a search for systematic reviews and meta-analyses in Medline via PubMed, the Cochrane Library, CINAHL, Gerolit, Embase, Psyndex, and Livivo, and hand-searched additional sources. Second, references of all relevant randomized controlled trials (n=86) were extracted from the identified systematic reviews (n=27). The original articles of the included primary studies were then analyzed using criteria for the evaluation of complex interventions. The GRADE approach was used to assess the quality of the evidence.

RESULTS

Seventeen interventions for promoting the psychosocial health of nursing home residents were identified. The majority of the study participants were nursing home residents with dementia. Since the underlying evidence was predominantly very low, it was not possible to draw clear conclusions concerning the efficacy of the interventions for psychosocial health outcomes. The best indications of positive effects were found for reminiscence, mealtime interventions, music therapy, and special care staff training.

CONCLUSION

The diversity and heterogeneity of the interventions made both classification and consistent judgments of the quality of the evidence difficult. From the perspective of promoting the psychosocial health of nursing home residents, the identified interventions should only be considered as suggestions or proposals for prevention and health promotion measures, and future studies should evaluate their implementation.

Exploring the role of external experts in supporting staff to implement psychosocial interventions in care home settings: results from the process evaluation of a randomized controlled trial

BACKGROUND

Psychosocial interventions offer opportunities to improve care for people with dementia in care homes. However, implementation is often led by staff who are not well prepared for the role. Some interventions use external experts to support staff. However little is known about external expert, care home staff and manager perceptions of such support. This paper addresses this gap.

METHODS

Multi-methods study within a process evaluation of a cluster randomised controlled trial of Dementia Care Mapping™ (DCM). Interviews were conducted with six external experts who also completed questionnaires, 17 care home managers and 25 care home staff responsible for DCM implementation. Data were analysed using descriptive statistics and template analysis.

RESULTS

Three themes were identified: the need for expert support, practicalities of support and broader impacts of providing support. Expert support was vital for successful DCM implementation, although the five-days provided was felt to be insufficient. Some homes felt the support was inflexible and did not consider their individual needs. Practical challenges of experts being located at a geographical distance from the care homes, limited when and how support was available. Experts gained knowledge they were able to then apply in delivering DCM training. Experts were not able to accurately predict which homes would be able to implement DCM independently in future cycles.

CONCLUSIONS

An external expert may form a key component of successful implementation of psychosocial interventions in care home settings. Future research should explore optimal use of the expert role.

Agitation near the end of life with dementia: An ethnographic study of care

Background and objectives

Agitation is common in people living with dementia especially at the end of life. We examined how staff interpreted agitation behavior in people with dementia nearing end of life, how this may influence their responses and its impact on the quality of care.

Research design

Ethnographic study. Structured and semi-structured non-participant observations (referred to subsequently in this paper as “structured observations”) of people living with dementia nearing the end of life in hospital and care homes (south-east England) and in-depth interviews with staff, conducted August 2015-March 2017.

Methods

Three data sources: 1) detailed field notes, 2) observations using a structured tool and checklist for behaviors classed as agitation and staff and institutional responses, 3) staff semi-structured qualitative interviews. We calculated the time participants were agitated and described staff responses. Data sources were analyzed separately, developed continuously and relationally during the study and synthesized where appropriate.

Results

We identified two main ‘ideal types’ of staff explanatory models for agitation: In the first, staff attribute agitated behaviors to the person’s “moral judgement”, making them prone to rejecting or punitive responses. In the second staff adopt a more “needs-based” approach in which agitation behaviors are regarded as meaningful and managed with proactive and investigative approaches. These different approaches appear to have significant consequences for the timing, frequency and quality of staff response. While these models may overlap they tend to reflect distinct organizational resources and values.

Conclusions

Care worker knowledge about agitation is not enough, and staff need organizational support to care better for people living with dementia towards end of life. Positional theory may help to explain much of the cultural-structural context that produces staff disengagement from people with dementia, offering insights on how agitation behavior is reframed by some staff as dangerous. Such behavior may be associated with low-resource institutions with minimal staff training where the personhood of staff may be neglected.

The Implementation of Dementia Care Mapping in a Randomized Controlled Trial in Long-Term Care: Results of a Process Evaluation

This study explored intervention implementation within a pragmatic, cluster randomized controlled trial of Dementia Care Mapping™ (DCM) in UK care homes. DCM is a practice development tool comprised of a 5 component cycle (staff briefing, mapping observations, data analysis and reporting, staff feedback, and action planning) that supports delivery of person-centered care. Two staff from the 31 intervention care homes were trained in DCM and asked to deliver 3 cycles over a 15-month period, supported by a DCM expert during cycle 1. Implementation data were collected after each mapping cycle. There was considerable variability in DCM implementation fidelity, dose, and reach. Not all homes trained 2 mappers on schedule, and some found it difficult to retain mappers. Only 26% of homes completed more than 1 cycle. Future DCM trials in care home settings should consider additional methods to support intervention completion including intervention delivery being conducted with ongoing external support.

Dementia Care in Canada: Nursing Recommendations

Au Canada, la prévention et la prise en charge des démences ont atteint un point tournant. Bien que le taux de diagnostic des démences soit encore bas, le nombre de personnes qui en sont atteintes continue d’augmenter. Les politiques canadiennes en matière de soins de santé ont fait en sorte qu’un plus grand nombre de personnes avec démence vivent à la maison, où les soins sont principalement assurés par la famille, des amis ou des proches. Cette Note de politique présente un aperçu d’un document conjoint de l’Association canadienne des infirmières et infirmiers en gérontologie (AIIG) et de l’Association des infirmières et infirmiers autorisés de l’Ontario (AIIAO) devant le Comité sénatorial permanent des affaires sociales, des sciences et de la technologie. Le document expose le cadre contextuel et les recommandations pour les soins liés à la démence au Canada dans cinq domaines clés : les ressources du système de santé, la formation des prestataires de soins de santé, le logement, les partenaires de soins et l’intégration des soutiens offerts en services sociaux et de santé. Dans le cadre de ces cinq domaines clés, des interventions en matière de santé et de politiques sociales ont été examinées.

What influences the sustainability of an effective psychosocial intervention for people with dementia living in care homes? A 9 to 12-month follow-up of the perceptions of staff in care homes involved in the WHELD randomised controlled trail

OBJECTIVES

The study aims to understand the factors that care home staff felt enabled or hindered them in continuing to use the well-being and health for people with dementia (WHELD) psychosocial approach in their care home and investigate whether there was sustained activity 9 to 12 months after the study ended.

METHODS

This qualitative study is part of a wider clinical trial, which demonstrated effectiveness of a psychosocial intervention on quality of life outcomes and neuropsychiatric symptoms for residents. Forty-seven care home staff within nine care homes in the United Kingdom participated in focus groups, between 9 and 12 months after the intervention had finished. Inductive thematic analysis was used to identify themes and interpret the data.

RESULTS

The findings highlighted that staff continued to use a range of activities and processes acquired through the research intervention, after the study had ended. Three overarching themes were identified as influential: "recognising the value" of the approach for residents and staff, "being well practiced" with sufficient support and opportunity to consolidate skills prior to the withdrawal of the researchers, and "taking ownership of the approach" to incorporate it as usual care.

CONCLUSIONS

The WHELD approach can be sustained where the value of the approach is recognised, and sufficient support is provided during initial implementation for staff to build skills and confidence for it to become routine care. Further follow-up is required to understand longer term use and the impact for residents.

Effect of person-centred care on antipsychotic drug use in nursing homes (EPCentCare): a cluster-randomised controlled trial

BACKGROUND

antipsychotic drugs are regularly prescribed as first-line treatment for neuropsychiatric symptoms in persons with dementia although guidelines clearly prioritise non-pharmacological interventions.

OBJECTIVE

we investigated a person-centred care approach, which has been successfully evaluated in nursing homes in the UK, and adapted it to German conditions.

DESIGN

a 2-armed 12-month cluster-randomised controlled trial.

SETTING

nursing homes in East, North and West Germany.

METHODS

all prescribing physicians from both study arms received medication reviews for individual patients and were offered access to 2 h of continuing medical education. Nursing homes in the intervention group received educational interventions on person-centred care and a continuous supervision programme. Primary outcome: proportion of residents receiving at least one antipsychotic prescription after 12 months of follow-up. Secondary outcomes: quality of life, agitated behaviour, falls and fall-related medical attention, a health economics evaluation and a process evaluation.

RESULTS

the study was conducted in 37 nursing homes with n = 1,153 residents (intervention group: n = 493; control group: n = 660). The proportion of residents with at least one antipsychotic medication changed after 12 months from 44.6% to 44.8% in the intervention group and from 39.8 to 33.3% in the control group. After 12 months, the difference in the prevalence was 11.4% between the intervention and control groups (95% confidence interval: 0.9-21.9; P = 0.033); odds ratio: 1.621 (95% confidence interval: 1.038-2.532).

CONCLUSIONS

the implementation of a proven person-centred care approach adapted to national conditions did not reduce antipsychotic prescriptions in German nursing homes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02295462.

Barriers and facilitators to implementing dementia care mapping in care homes: results from the DCM™ EPIC trial process evaluation

Background

Psychosocial person-centred interventions are considered best practice for addressing complex behaviours and care needs such as agitation and anxiety, and for improving the quality of life of people with dementia in care homes. Dementia Care Mapping (DCM™) is an established practice development tool and process aimed to help care home staff deliver more person-centred care. To date, few studies have evaluated the efficacy of DCM™ and have found mixed results. These results are suggested to be the outcome of intervention implementation, which may be impacted by a range of factors. This study reports the barriers and facilitators to DCM™ implementation in care homes found during the process evaluation conducted as part of a randomized controlled trial.

Methods

Eighteen of the 31 DCM™ intervention care homes were recruited to participate in the embedded process evaluation. Semi-structured interviews were conducted with 83 participants, comprising care home managers, trained DCM™ users (mappers), expert external mappers, staff members, relatives, and residents.

Results

Barriers and facilitators to DCM™ implementation were found at the mapper level (e.g. motivation and confidence), the DCM™ intervention level (e.g. understanding of DCM™) and the care home level (e.g. staffing issues, manager support). Further barriers caused by the burden of trial participation were also identified (e.g. additional paperwork).

Conclusions

Implementing DCM™ is complex and a greater consideration of potential barriers and facilitators in planning future studies and in practice could help improve implementation.

Trial registration

Current Controlled Trials ISRCTN82288852, registered 16/01/2014.