Influence of Individual and Contextual Characteristics on the Provision of Individualized Care in Long-Term Care Facilities

Caspar, Sienna; Cooke, Heather A; O’Rourke, Norm; MacDonald, Stuart W. S.

doi:10.1093/geront/gns165

Cited by 38 publications

(35 citation statements)

References 27 publications

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“…Reflecting on the question of what had contributed to the improvement of daily activities and the development of cultural values associated with person-centred care, this research largely confirms that of earlier research [6,9,13,14,51]. The promotion of dialogue, participation and influence of the staff during every phase of the project, joint decision-making and continuous appreciative and adaptive facilitation all contributed to transformational change.…”

Section: Discussionsupporting

confidence: 79%

“…She indicates that deep culture change is rare and that the adoption of culture change and person-centred practices remains inadequate, although the awareness of the culture change movement has grown in recent years. The main challenges to fundamental change seem to be staff motivation and vision, relationships between staff, residents and family, team work, and empowerment of staff [9,13,53,64]. Such challenges could be met by developing new shared cultural values, deep beliefs and patterns of unconscious basic assumptions [8,13,37,52,64].…”

Section: Introductionmentioning

confidence: 99%

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Nurturing Cultural Change in Care for Older People: Seeing the Cherry Tree Blossom

et al. 2014

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There is a need for person-centred approaches and empowerment of staff within the residential care for older people; a movement called 'culture change'. There is however no single path for achieving culture change. With the aim of increasing understandings about cultural change processes and the promotion of cultural values and norms associated with person-centred practices, this article presents an action research project set on a unit in the Netherlands providing care for older people with dementia. The project is presented as a case study. This study examines what has contributed to the improvement of participation of older people with dementia in daily occupational and leisure activities according to practitioners. Data was collected by participant observation, interviews and focus groups. The results show that simultaneous to the improvement of the older people's involvement in daily activities a cultural transformation took place and that the care became more person-centred. Spontaneous interactions and responses rather than planned interventions, analysis and reflection contributed to this. Furthermore, it proved to be beneficial that the process of change and the facilitation of that process reflected the same values as those underlying the cultural change. It is concluded that changes arise from dynamic, interactive and non-linear processes which are complex in nature and difficult to predict and to control. Nevertheless, managers and facilitators can facilitate such change by generating movement through the introduction of small focused projects that meet the stakeholders' needs, by creating conditions for interaction and sense making, and by promoting the new desired cultural values.

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Section: Discussionsupporting

confidence: 79%

Section: Introductionmentioning

confidence: 99%

Nurturing Cultural Change in Care for Older People: Seeing the Cherry Tree Blossom

et al. 2014

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“…To date, when attempting to advance our knowledge regarding meaningful improvements to the provision of care delivery in LTC settings, the role of culture remains vague, with the primary focus being on contextual-level (i.e., facility) characteristics [30]. The NCAT was conceptualized as six dimensions that were proposed to capture the unique nursing ethos within each setting that drives care delivery beliefs, values, and practice norms, as presented in Fig.…”

Section: Theoretical Implicationsmentioning

confidence: 99%

Nursing culture assessment tool (NCAT): Empirical validation for use in long-term care

Yap

Kennerly

Flint

2014

International Journal of Nursing Sciences

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“…Managerial support was also highlighted as important for the delivery of interventions in care home settings in a successful intervention in Australia 210 and in an implementation study of the FITS care home intervention in the UK. 84 Staff perceptions of empowerment within their work environment can exert considerable influence on the delivery of individualised care, 172 which is also a prerequisite for case-specific intervention in dementia and CB. Disappointingly in our case studies, we found examples of managers who were unable to value their 'staff champions' by providing encouragement to use the resources, such as the technology and training opportunities we provided.…”

Section: Discussionmentioning

confidence: 99%

“…Barriers to delivery of the intervention to reduce antipsychotics in the FITS implementation study included unclear communication across management levels and values and ethos that contradicted the intervention approach. 84 Other studies have noted that staff perceptions of empowerment are important in the provision of individualised care; 172 values and beliefs that guide behaviour in an organisation can have an impact on depressive symptoms in nursing home residents; 173 and the impact of training initiatives on staff confidence and standards of care is often dependent on strong leadership and the home culture. 174 We will now consider our findings in the context of fidelity and adherence to the intervention.…”

Section: Limitations and Implications For Researchmentioning

confidence: 99%

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Moniz–Cook

Hart

Woods

et al. 2017

Programme Grants Appl Res

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BackgroundDementia with challenging behaviour (CB) causes significant distress for caregivers and the person with dementia. It is associated with breakdown of care at home and disruption in care homes. Challenge Demcare aimed to assist care home staff and mental health practitioners who support families at home to respond effectively to CB.ObjectivesTo study the management of CB in care homes (ResCare) and in family care (FamCare). Following a conceptual overview, two systematic reviews and scrutiny of clinical guidelines, we (1) developed and tested a computerised intervention; (2) conducted a cluster randomised trial (CRT) of the intervention for dementia with CB in care homes; (3) conducted a process evaluation of implementation of the intervention; and (4) conducted a longitudinal observational cohort study of the management of people with dementia with CB living at home, and their carers.Review methodsCochrane review of randomised controlled trials; systematic meta-ethnographic review of quantitative and qualitative studies.DesignResCare – survey, CRT, process evaluation and stakeholder consultations. FamCare – survey, longitudinal cohort study, participatory development design process and stakeholder consultations. Comparative examination of baseline levels of CB in the ResCare trial and the FamCare study participants.SettingsResCare – 63 care homes in Yorkshire. FamCare – 33 community mental health teams for older people (CMHTsOP) in seven NHS organisations across England.ParticipantsResCare – 2386 residents and 861 staff screened for eligibility; 555 residents with dementia and CB; 277 ‘other’ residents; 632 care staff; and 92 staff champions. FamCare – every new referral (n = 5360) reviewed for eligibility; 157 patients with dementia and CB, with their carer; and 26 mental health practitioners. Stakeholder consultations – initial workshops with 83 practitioners and managers from participating organisations; and 70 additional stakeholders using eight group discussions and nine individual interviews.InterventionAn online application for case-specific action plans to reduce CB in dementia, consisting of e-learning and bespoke decision support care home and family care e-tools.Main outcome measuresResCare – survey with the Challenging Behaviour Scale; measurement of CB with the Neuropsychiatric Inventory (NPI) and medications taken from prescriptions; implementation with thematic views from participants and stakeholders. FamCare – case identification from all referrals to CMHTsOP; measurement of CB with the Revised Memory and Behaviour Problems Checklist and NPI; medications taken from prescriptions; and thematic views from stakeholders. Costs of care calculated for both settings. Comparison of the ResCare trial and FamCare study participants used the NPI, Clinical Dementia Rating and prescribed medications.ResultsResCare – training with group discussion and decision support for individualised interventions did not change practice enough to have an impact on CB in dementia. Worksite e-learning opportunities were not readily taken up by care home staff. Smaller homes with a less hierarchical management appear more ready than others to engage in innovation. FamCare – home-dwelling people with dementia and CB are referred to specialist NHS services, but treatment over 6 months, averaging nine contacts per family, had no overall impact on CB. Over 60% of people with CB had mild dementia. Families bear the majority of the care costs of dementia with CB. A care gap in the delivery of post-diagnostic help for families supporting relatives with dementia and significant CB at home has emerged. Higher levels of CB were recorded in family settings; and prescribing practices were suboptimal in both care home and family settings.LimitationsFunctionality of the software was unreliable, resulting in delays. This compromised the feasibility studies and undermined delivery of the intervention in care homes. A planned FamCare CRT could not proceed because of insufficient referrals.ConclusionsA Cochrane review of individualised functional analysis-based interventions suggests that these show promise, although delivery requires a trained dementia care workforce. Like many staff training interventions, our interactive e-learning course was well received by staff when delivered in groups with facilitated discussion. Our e-learning and decision support e-tool intervention in care homes, in its current form, without ongoing review of implementation of recommended action plans, is not effective at reducing CB when compared with usual care. This may also be true for staff training in general. A shift in priorities from early diagnosis to early recognition of dementia with clinically significant CB could bridge the emerging gap and inequities of care to families. Formalised service improvements in the NHS, to co-ordinate such interventions, may stimulate better opportunities for practice models and pathways. Separate services for care homes and family care may enhance the efficiency of delivery and the quality of research on implementation into routine care.Future workThere is scope for extending functional analysis-based interventions with communication and interaction training for carers. Our clinical workbooks, video material of real-life episodes of CB and process evaluation tool resources require further testing. There is an urgent need for evaluation of interventions for home-dwelling people with dementia with clinically significant CB, delivered by trained dementia practitioners. Realist evaluation designs may illuminate how the intervention might work, and for whom, within varying service contexts.Trial registrationCurrent Controlled Trials ISRCTN02553381 (the ResCare trial) and ISRCTN58876649 (the FamCare study).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 15. See the NIHR Journals Library website for further project information.

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Influence of Individual and Contextual Characteristics on the Provision of Individualized Care in Long-Term Care Facilities

Cited by 38 publications

References 27 publications

Nurturing Cultural Change in Care for Older People: Seeing the Cherry Tree Blossom

Nurturing Cultural Change in Care for Older People: Seeing the Cherry Tree Blossom

Nursing culture assessment tool (NCAT): Empirical validation for use in long-term care

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

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