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Implementing Dementia Care Mapping to Develop Person-Centred Care: Results of a Process Evaluation within the Leben-QD II Trial
Journal of Clinical Nursing
Abstract
Aims and objective:
To evaluate Dementia Care Mapping (DCM) implementation in nursing homes.
Background:
DCM, an internationally applied method for supporting and enhancing person-centred care (PCC) for people with dementia, must be successfully implemented into care practice for its effective use. Various factors influence the implementation of complex interventions such as DCM; few studies have examined specific factors influencing DCM implementation.
Design:
A convergent parallel mixed methods design embedded in a quasi-experimental trial was used to assess DCM implementation success and influential factors.
Methods:
From 2011 to 2013, nine nursing units in nine different nursing homes implemented either DCM (n=6) or a periodic quality of life measurement using the dementia-specific instrument QUALIDEM (n=3). Diverse data (interviews, n=27; questionnaires, n=112; resident records, n=81; and process documents) were collected. Each data set was separately analysed and then merged to comprehensively portray the implementation process.
Results:
Four nursing units implemented the particular intervention without deviating from the pre-planned intervention. Translating DCM results into practice was challenging. Necessary organisational preconditions for DCM implementation included well-functioning networks, a dementia-friendly culture, and flexible organisational structures. Involved individuals' positive attitudes towards DCM also facilitated implementation. Precisely planning the intervention and its implementation, recruiting champions who supported DCM implementation, and having well-qualified, experienced project coordinators were essential to the implementation process.
Conclusions:
For successful DCM implementation, it must be embedded in a systematic implementation strategy considering the specific setting. Organisational preconditions may need to be developed before DCM implementation. Necessary steps may include team building, developing and realising a PCC-based mission statement, or educating staff regarding general dementia care. The implementation strategy may include attracting and involving individuals on different hierarchical levels in DCM implementation and supporting staff to translate DCM results into practice.
Relevance to practice:
The identified facilitating factors can guide DCM implementation strategy development. This article is protected by copyright. All rights reserved.
... Since it was developed, DCM has been used as a form of systematic observation in a variety of international care contexts, such as care homes, hospitals, and day centres, with the newest edition of the DCM manual (DCM 8) (Brooker and Surr, 2006) being validated in several service settings in the UK and revised and refined across several international working groups (Brooker, 2005;Brooker and Surr, 2006;McIntosh et al., 2012;Quasdorf et al., 2017;Surr et al., 2019a;Surr, Griffiths, and Kelley, 2018). ...
... The same barriers were found in another study (Quasdorf et al., 2017), as individual mappers lacked knowledge about what the intervention meant and had negative attitudes towards the implementation of DCM. This translated into mappers failing to translate data from cycles of mapping into action plans for daily care practice. ...
... This translated into mappers failing to translate data from cycles of mapping into action plans for daily care practice. When implementing DCM, the choice of mappers acted as a barrier to implementation (Griffiths et al., 2019;Kelley et al., 2020;Quasdorf et al., 2017;Surr et al., 2021). This was seen as an obvious problem when mappers still failed to understand the process and expected role after the trial ended, mentioning that they felt unprepared and unskilled to implement a complex DCM intervention (Kelley et al., 2020). ...
Context: Dementia care mapping (DCM) is a multicomponent intervention to deliver person-centred care (PCC) for people with dementia. While the research has demonstrated the positive impact of DCM in care homes, more needs to be understood about the contexts and underlying mechanisms that may affect its implementation and uptake. Objective: This review aims to develop a theoretical understanding of what influences the successful implementation of PCC, specifically DCM in care homes. Method: A realist review was conducted using an iterative, stakeholder-driven, two-stage approach. Several databases were searched to identify studies published in English from 2000 to 2022. Seven DCM expert mappers took part in the focus group. We followed a descriptive, narrative approach to explain the results. Findings: We found that an individual’s knowledge and skills of DCM can either be a barrier or a facilitator. Limited managerial support and communication among staff and high staff turnover rates were identified as significant barriers to implementing DCM. Leadership support, open communication channels and supportive relationships between staff members facilitated implementation. Limitations: There may be documents used in practice in diverse care settings that provide information to build on the review. Literature from other countries could have been missed. Implications: A successful intervention in care homes requires facilitating mechanisms that can support the staff and wider care team to engage with the intervention. Long-term care policies should prioritise evidence-based practices, leadership development, effective communication, and a deep understanding of staff motivations and organisational culture to successfully implement DCM and other PCC interventions.
... Although complex interventions can be effective [21], to date they have tended to have relatively small or lacking effects [16,22,23], with suboptimal implementation emerging as a prime reason. Process evaluations in NHs have demonstrated that suboptimal implementation results from barriers [24][25][26], not least of which are skepticism about using nonpharmacological approaches [27]. From a broader healthcare perspective, implementation problems relate to perceptions that the issue is not a priority [28], and the use of standardized "one size fits all" solutions [20]. ...
... Complex healthcare interventions may work best if tailored to local circumstances rather than being standardized [20,28], especially if they identify and target modifiable barriers to change before implementation [28,29]. Consistent with this, process evaluations of complex interventions among NH residents with dementia have underlined that we must adapt to the specific needs and features of each care organization [24,26]. It also appears that collaborative approaches that introduce external expertise can address the concerns and problems faced by NH staff, while ensuring awareness of their preferences and increasing awareness [30]. ...
... Communication issues impeded implementation in our study, which is again consistent with previous research [24,26]. Notably, our problem analysis revealed that many NHs struggled with there being little interdisciplinary contact. ...
Background
Research suggests that collaborative and tailored approaches with external expertise are important to process implementations. We therefore performed a process evaluation of an intervention using participatory action research, tailored information provision, and external coaching to reduce inappropriate psychotropic drug use among nursing home residents with dementia. The process evaluation was conducted alongside a randomized controlled trial assessing the utility of this approach.
Methods
We used Leontjevas’ model of process evaluation to guide data collection and analysis, focusing on the relevance and feasibility, extent of performance, and barriers and facilitators to implementation. Data on the relevance and feasibility and on the extent of performance were collected using a questionnaire targeting internal project leaders at nursing homes and our external coaches. Implementation barriers and facilitators were identified by individual semi-structured interviews. The Consolidated Framework for Implementation Research was used to structure and describe the identified barriers and facilitators.
Results
The intervention was viewed positively, but it was also considered time consuming due to the involvement of many people and designing a tailored action and implementation plan was viewed as complex. The extent of performance differed between nursing homes. Delays in implementation and suboptimal execution of actions may have reduced effectiveness of the RID intervention in some nursing homes. Barriers to implementation were reorganizations, staff turnover, communication issues, unclear expectations, and perceived time pressures. Implementation also depended on the involvement and skills of key stakeholders, and organizations’ readiness to change. Although external coaches stimulated implementation, their additional value was rated variably across organizations.
Conclusions
Barriers to implementation occurred on several levels and some barriers appear to be inherent to the nursing home environment and could be points of leverage of future implementation trajectories. This underlines the importance of assessing and supporting organizations in their readiness to change. Sensitivity analyses, taking into account the week in which nursing homes started with implementation and the degree to which actions were implemented as intended, will be appropriate in the effect analyses of the trial.
... with many facing both budget constraints and difficulties in recruiting and retaining staff. Some studies noted that in a context in which staff retention was often problematic for care homes, having stable teams was beneficial for PCC to bed down (Quasdorf et al., 2017, Sullivan et al., 2013. ...
... Care home models that included management and leadership as part of their approach to providing personalisation (e.g. Green House) addressed such challenges upfront and might have an advantage as a consequence, although the success of such models depended on whether they were implemented as intended (Petriwskyj et al., 2016a, Quasdorf et al., 2017. However, many studies were insufficiently specific about the precise models of care operational in practice (Petriwskyj et al., 2016a). ...
... None of the studies we identified in this category examined the effects of management or leadership on user outcomes, although these factors were often discussed as facilitators or barriers when authors considered the implications of their findings (e.g. Quasdorf et al., 2017). This is particularly striking, as the role of the manager is a central concern in the inspections of care homes by the CQC, with an entire domain of the inspection framework being dedicated to the care home management (i.e. ...
... Important factors for successful implementation are, e.g. easiness to apply the intervention in every care, leadership engagement (Quasdorf et al., 2017;Rapaport et al., 2017), a dementia-friendly culture (e.g. flexible organizational structures), established networks, and support of local champions (Quasdorf et al., 2017). ...
... easiness to apply the intervention in every care, leadership engagement (Quasdorf et al., 2017;Rapaport et al., 2017), a dementia-friendly culture (e.g. flexible organizational structures), established networks, and support of local champions (Quasdorf et al., 2017). Barriers are, e.g. ...
... Barriers are, e.g. insufficient resources (Boersma et al., 2017) and staff turnover (Boersma et al., 2017;Quasdorf et al., 2017). ...
Background
Dementia guidelines propose the use of nonpharmacological interventions for sleep disturbances for older people. Based on available reviews, it seems most likely that multicomponent interventions have the strongest potential to be effective in improving sleep. However, a detailed description of multicomponent interventions is missing. This systematic review aims to identify, describe, and summarize multicomponent, nonpharmacological interventions to reduce or avoid sleep disturbances in nursing home residents.
Methods
This review followed established methodological frameworks for systematic evidence syntheses. A computerized search was conducted in December 2018, using the databases PubMed, CINAHL, Scopus, and Cochrane Library. Two independent reviewers assessed all search results to identify eligible studies and assessed studies’ methodological quality following the Cochrane Risk of Bias methodology for randomized controlled trials and the CASP Appraisal Checklist for controlled trials.
Evaluation studies of any design investigating multicomponent interventions were included, except case studies. Components of included intervention programs were analyzed applying the TIDieR and CReDECI 2 criteria.
Results
A total of 2056 studies were identified through the database search; ten publications about nine interventions met the inclusion criteria and were included in the review. The identified interventions can be summarized assigned to the categories “daytime activities,” “nighttime activities,” “staff training,” and “light exposure.” The approaches showed similarities and differences in procedures, materials, modes of delivery, intervention provider, and intervention period. None of the studies described any intended interactions between components or considered context characteristics in intervention modeling as well as internal and external facilitators or barriers influencing delivery of intervention. We identified positive or mixed positive effects for sleep-related outcomes for the mentioned categories.
Conclusions
The analysis of included interventions demonstrates somehow promising results, although findings are difficult to interpret as interventions were not well described, and the challenges of developing and evaluating complex interventions were not sufficiently acknowledged.
... A variety of determinants are said to be important, such as improved relationships with residents, teamwork and leadership, as well as a range of organizational factors like staffing, workload, flexibility of the organization and availability of a clear implementation plan. 15À18 Many of these studies emphasized the effect of nursing staff attitudes towards the intervention, 15,19 as nursing staff are often the primary change agents carrying out the intervention in their day-to-day routines. Thus, the current study specifically examines the perspective of nursing staff regarding potential determinants for the implementation and continued use of an intervention. ...
... The results showed that missing a clear implementation plan and having an unstable context were the most important barriers for actual implementation of this component. Previous studies also found that nursing staff required detailed instructions regarding how to implement interventions, 16,19 challenging the recommendation of using flexible implementation plans. 33 Others also reported the impeding effect of going through a restructure. ...
... Compatibility with daily work facilitated the intention to use this component, in line with a meta-analysis of qualitative research of psychosocial interventions for people with dementia. 34 Support from colleagues facilitated actual implementation of these small behavior changes, comparable to previous studies showing the facilitative effect of well-functioning teams, 19,33 and the impeding effects of collaboration problems. 15 Interviewees in our study indicated that the decision to implement an intervention was a team-endeavor and outlined that entire units can exhibit PCC climate. ...
Person-centered care (PCC) interventions have the potential to improve resident well-being in nursing homes, but can be difficult to implement. This study investigates perceived facilitators and barriers reported by nursing staff to using a PCC intervention consisting of three components: assessment of resident well-being, planning of well-being support, and behavioral changes in care to support resident well-being. Our explorative mixed method study combined interviews (n = 11) with a longitudinal survey (n = 132) to examine which determinants were most prevalent and predictive for intention to use the intervention and actual implementation 3 months later (n = 63). Results showed that perceived barriers and facilitators were dependent on the components of the intervention. Assessment of resident well-being required a stable nursing home context and a detailed implementation plan, while planning of well-being support was impeded by knowledge. Behavioral changes in nursing care required easy integration in daily caring tasks and social support.
... Table 1 displays characteristics of included studies. Most of the studies were from the Netherlands [19,21,29,30,37,42] and the UK [23,25,28,32,33,40] (each n = 6), followed by Australia [24,34,41], Canada [20,22,27], Norway [26,31,36] (each n = 3), Germany [38,39], and Belgium [18,43] (each n = 2). One multinational study took place in Italy and the Netherlands [35]. ...
... Data concerning barriers and facilitators were collected through interviews [10,43] (n = 24), by means of questionnaires [19,23,24,31,38] (n = 6), field notes or process data notes [26,32,37,38] (n = 4), observation [25,39,40] (n = 3), workshops [36] (n = 1), written evaluations by trainers/instructors [37] (n = 1), residents' records [38] (n = 1) and/or by asking openended questions [18] (n = 1). Qualitative data were analysed using thematic or content analysis [18-27, 29, 31-42] (n = 23) or framework analysis [28,32] (n = 2). ...
... Data concerning barriers and facilitators were collected through interviews [10,43] (n = 24), by means of questionnaires [19,23,24,31,38] (n = 6), field notes or process data notes [26,32,37,38] (n = 4), observation [25,39,40] (n = 3), workshops [36] (n = 1), written evaluations by trainers/instructors [37] (n = 1), residents' records [38] (n = 1) and/or by asking openended questions [18] (n = 1). Qualitative data were analysed using thematic or content analysis [18-27, 29, 31-42] (n = 23) or framework analysis [28,32] (n = 2). ...
Background:
The implementation of evidence-based interventions for people with dementia is complex and challenging. However, successful implementation might be a key element to ensure evidence-based practice and high quality of care. There is a need to improve implementation processes in dementia care by better understanding the arising challenges. Thus, the aim of this study was to identify recent knowledge concerning barriers and facilitators to implementing nurse-led interventions in dementia care.
Methods:
We performed a scoping review using the methodological framework of Arksey and O'Malley. Studies explicitly reporting on the implementation process and factors influencing the implementation of a nurse-led intervention in dementia care in all settings were included. We searched eight databases from January 2015 until January 2019. Two authors independently selected the studies. For data analysis, we used an inductive approach to build domains and categories.
Results:
We included 26 studies in the review and identified barriers as well as facilitators in five domains: policy (e.g. financing issues, health insurance), organisation (e.g. organisational culture and vision, resources, management support), intervention/implementation (e.g. complexity of the intervention, perceived value of the intervention), staff (e.g. knowledge, experience and skills, attitude towards the intervention), and person with dementia/family (e.g. nature and stage of dementia, response of persons with dementia and their families).
Conclusions:
Besides general influencing factors for implementing nursing interventions, we identified dementia-specific factors reaching beyond already known barriers and facilitators. A pre-existing person-centred culture of care as well as consistent team cultures and attitudes have a facilitating effect on implementation processes. Furthermore, there is a need for interventions that are highly flexible and sensitive to patients' condition, needs and behaviour.
... Although complex interventions have the potential to reduce inappropriate prescribing of antipsychotic drugs in NHs (Livingston et al., 2017;Thompson Coon et al., 2014), these interventions commonly show small to modest effects (O'Connor et al., 2009;Quasdorf et al., 2016;Zwijsen et al., 2014a), which often reflects suboptimal implementation rather than shortcomings of the implemented intervention (Anderson et al., 2013;Craig et al., 2013). ...
... To examine barriers and facilitators influencing the implementation of complex interventions for people with dementia in long-term care, we reviewed literature on process evaluations, qualitative studies, and (cluster) randomized controlled trials targeting NPS and/or psychotropic drug use (PDU). By assembling knowledge about factors influencing implementation of complex interventions, effectiveness of interventions can be maximized, and translating results into practice is enabled which in turn enhances widespread implementation (Craig et al., 2013;Lawrence et al., 2012;Thompson Coon et al., 2014;Quasdorf et al., 2016;Zwijsen et al., 2014b). ...
... Table 2 provides a detailed overview of the quality assessments of the studies. On a scale from 0 to 10 (the higher the more quality), five studies scored 5 to 7 points (Borbasi et al., 2011;Kovach et al., 2008;McAiney et al., 2007;Stein-Parbury et al., 2012;Wingenfeld et al., 2011), and ten studies scored 8 to 10 points (Appelhof et al., 2018;Boersma et al., 2016;Bourbonnais et al., 2018;Ellard et al., 2014;Van Haeften-Van Dijk et al., 2015;Latham and Brooker, 2017;Lawrence et al., 2016;Mekki et al., 2017;Quasdorf et al., 2016;Zwijsen et al., 2014b). ...
Objectives
Psychotropic drugs are frequently and sometimes inappropriately used for the treatment of neuropsychiatric symptoms of people with dementia, despite their limited efficacy and side effects. Interventions to address neuropsychiatric symptoms and psychotropic drug use are multifactorial and often multidisciplinary. Suboptimal implementation of these complex interventions often limits their effectiveness. This systematic review provides an overview of barriers and facilitators influencing the implementation of complex interventions targeting neuropsychiatric symptoms and psychotropic drug use in long-term care.
Design
To identify relevant studies, the following electronic databases were searched between 28 May and 4 June: PubMed, Web of Science, PsycINFO, Cochrane, and CINAHL. Two reviewers systematically reviewed the literature, and the quality of the included studies was assessed using the Critical Appraisal Skills Programme qualitative checklist. The frequency of barriers and facilitators was addressed, followed by deductive thematic analysis describing their positive of negative influence. The Consolidated Framework for Implementation Research guided data synthesis.
Results
Fifteen studies were included, using mostly a combination of intervention types and care programs, as well as different implementation strategies. Key factors to successful implementation included strong leadership and support of champions. Also, communication and coordination between disciplines, management support, sufficient resources, and culture (e.g. openness to change) influenced implementation positively. Barriers related mostly to unstable organizations, such as renovations to facility, changes toward self-directed teams, high staff turnover, and perceived work and time pressures.
Conclusions
Implementation is complex and needs to be tailored to the specific needs and characteristics of the organization in question. Champions should be carefully chosen, and the application of learned actions and knowledge into practice is expected to further improve implementation.
... There remains limited robust evidence evaluating the features of successful DCM implementation [29]. As with other care home interventions, common challenges include the time requirements for training, mapping, feeding back and implementing changes [21,30]; workload and staffing pressures [23,31]; trained staff ('mappers') not feeling adequately prepared to implement DCM [32]; and lack of organisational and/ or management support [21,25,31]. ...
... There remains limited robust evidence evaluating the features of successful DCM implementation [29]. As with other care home interventions, common challenges include the time requirements for training, mapping, feeding back and implementing changes [21,30]; workload and staffing pressures [23,31]; trained staff ('mappers') not feeling adequately prepared to implement DCM [32]; and lack of organisational and/ or management support [21,25,31]. ...
... This study has identified that support from an external expert was essential to successful implementation of DCM by care home mappers. The benefits of external support for implementing interventions in care homes has been reported in other research [41] including evidence from previous research on DCM, which found support for new mappers by experienced in-house mappers facilitated implementation [31]. Experts and mappers indicated the 5 days of support provided were not sufficient to support a full cycle of DCM. ...
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.
... In recent decades, a number of multidisciplinary care programs have been developed to target the factors associated with inappropriate prescribing and/or to shift practice toward a greater use of non-pharmacological interventions (e.g., STA-OP, GRIP, PROPER, AiD, Dementia Care Mapping, RedUSe, and TIME) [28][29][30][31][32][33][34]. RedUSe is a good example of a multi-strategic interdisciplinary intervention that took place in 150 residential aged care facilities and was shown to reduce antipsychotic prescribing by 13% and benzodiazepine prescribing by 21%, without increasing their pro re nata use. ...
... Staff turnover, experience of concurrent and former projects, and organizational change have also been considered important organizational barriers [39]. By contrast, organizational preconditions for implementation are the presence of wellfunctioning networks, flexible organizational structures, a dementia-friendly culture, and positive attitudes of involved staff [32]. ...
... As one might imagine, creating a change in NH practice can be challenging given the complex nature of these institutions. Consequently, standardized interventions are less likely to be successful, with a need to emphasize the specific organizational features of a NH and their culture to better adapt to their specific needs [27,32,38,39]. A prerequisite for successful implementation of any psychosocial intervention, whether person-centered or multidisciplinary, must therefore be that it includes some degree of tailoring. ...
Background:
Psychotropic drugs are often prescribed to treat neuropsychiatric symptoms in nursing home residents with dementia, despite having limited efficacy and considerable side effects. To reduce the inappropriate prescribing of these psychotropic drugs, various non-pharmacological, psychosocial, person-centered, or multidisciplinary interventions are advocated. However, existing multidisciplinary interventions have shown variable effects, with limited effectiveness often resulting from suboptimal implementation. We hypothesize that an effective intervention needs to fit the local situation of a nursing home and that support should be offered during implementation.
Methods:
We will embed participatory action research within a stepped-wedge cluster randomized controlled trial to study the effects of a tailored intervention and implementation plan to reduce inappropriate psychotropic drug prescribing. Nursing homes will be provided with tailored information about the perceived problems of managing neuropsychiatric symptoms and we will offer coaching support throughout. Alongside the participatory action research, we will perform a process evaluation to examine the quality of the study, the intervention, and the implementation. Our aim is to recruit 600 residents from 16 nursing homes throughout the Netherlands, with measurements taken at baseline, 8 months, and 16 months. Nursing homes will be randomly allocated to an intervention or a deferred intervention group. During each intervention stage, we will provide information about inappropriate psychotropic drug prescribing, neuropsychiatric symptoms, and difficulties in managing neuropsychiatric symptoms through collaboration with each nursing home. After this, a tailored intervention and implementation plan will be written and implemented, guided by a coach. The primary outcome will be the reduction of inappropriate prescribing, as measured by the Appropriate Psychotropic drug use In Dementia index. Secondary outcomes will be the frequency of psychotropic drug use and neuropsychiatric symptoms, plus quality of life. A mixed methods design will be used for the process evaluation. Effects will be assessed using multilevel analyses. The project leader of the nursing home and the coach will complete questionnaires and in-depth interviews.
Discussion:
We anticipate that the proposed tailored intervention with coaching will reduce inappropriate psychotropic drug prescribing for nursing home residents with neuropsychiatric symptoms. This study should also provide insights into the barriers to, and facilitators of, implementation.
Trial registration:
NTR5872 , registered on July 2, 2016.
... 26 Few DCM studies have been conducted as randomized controlled trials, with only 2 reporting full implementation procedures and process evaluation results. 27,28 Thus, relatively little is known about the particular DCM implementation strategies that have proved effective. 29 A German study reported largely good adherence to delivery of the requisite number of DCM cycles and cycle components. ...
... 29 A German study reported largely good adherence to delivery of the requisite number of DCM cycles and cycle components. 27 However, wider staff engagement in feedback sessions was low in 2 of the 6 intervention homes, and staff were critical of the quality of DCM delivery. In a Dutch study, involving 13 care units across 5 nursing home sites, DCM intervention adherence was variable. ...
... Low staff engagement with DCM was also reported in a previous process evaluation study. 27 When implementing complex interventions such as DCM in care home settings, engagement of the wider staff team 41,42 and good communication around implementation 43,44 are identified facilitators of adoption in practice. These factors were unlikely in homes where few staff were involved in DCM briefing or feedback. ...
This study explored intervention implementation within a pragmatic, cluster randomised controlled trial of Dementia Care MappingTM (DCM) in UK care homes. DCM is a practice development tool comprised of a five component cycle (staff briefing, mapping observations, data analysis and reporting, staff feedback, action planning) that supports delivery of person-centred care. Two staff from the 31 intervention care homes were trained in DCM and asked to deliver three 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 two mappers on schedule and some found it difficult to retain mappers. Only 26% of homes completed more than one 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.
... Of these six studies, only two have included a process evaluation [7,11], to allow the understanding of DCM implementation fidelity and processes. One of these in particular, highlighted issues with intervention fidelity within some of the clusters and recommended that process evaluations be conducted in further RCTs, in order to assess whether the intervention has actually been delivered as intended [7]. ...
... The culture of the care home was particularly important, ensuring that good relationships existed between mappers, managers and the wider staff team. This echoes the findings of Quasdorf and colleagues [11] who found that in order for DCM™ to be successfully implemented, the organisational context must include staff teams with little turnover, who communicated well and without hierarchies. However, this is an idealistic view and it is not clear how realistic such a structure is. ...
... This suggests that prior to implementation of DCM™, care home teams should be encouraged to evaluate their culture and identify whether any preliminary work needs to be done to allow DCM™ to be successfully implemented into the care home. This may include team building exercises [11] and identifying gaps in staff knowledge, to encourage a culture with a personcentred focus. As DCM™ needs to be integrated into practice over a period of time into order to be effective [15], it may also be important for DCM™ to be seen as a component of care homes' long term plans, rather than a standalone intervention. ...
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.
... Seven of the papers reported a formal evaluation of the DCM implementation process; in the other five studies, process issues were identified by the researchers in their discussion of DCM implementation in the project. Formal evaluation methods included surveys, 28,29 reflective diaries, 30 interviews and focus groups, [25][26][27]31 questionnaires and documentary analysis. 26,27 In five studies, there were no formal methods for evaluating DCM implementation or process issues; instead, these were detailed in the paper as part of the discussion and conclusion sections, based on the author(s) reflections on and critique of the implementation process. ...
... Formal evaluation methods included surveys, 28,29 reflective diaries, 30 interviews and focus groups, [25][26][27]31 questionnaires and documentary analysis. 26,27 In five studies, there were no formal methods for evaluating DCM implementation or process issues; instead, these were detailed in the paper as part of the discussion and conclusion sections, based on the author(s) reflections on and critique of the implementation process. The quality check demonstrated that methodological rigor was generally high, although there were some issues with potential bias in recruitment, 12,18,22 acceptable response rates 20,21 and awareness of potential researcher influence. ...
... As suggested by DCM guidance, 33 which states feedback should be timely and within a month of observation, all study authors highlighted the need for feedback to occur quickly -time lapses between mapping and feedback in the studies ranged from 24 hours to 1 week. One process evaluation of a quasiexperimental study of DCM in care homes 26 found that all but one of the six participating homes delivered a feedback session for each of the three cycles of mapping that took place. In two of the care homes, attendance of staff at feedback sessions was relatively low and in these units, staff ratings of the usefulness of feedback and the DCM process itself were negative. ...
Dementia Care Mapping (DCM) is an observational tool set within a practice development process. Following training in the method, DCM is implemented via a cyclic process of briefing staff, conducting mapping observations, data analysis and report preparation, feedback to staff and action planning. Recent controlled studies of DCM’s efficacy have found heterogeneous results, and variability in DCM implementation has been indicated as a potential contributing factor. This review aimed to examine the primary research evidence on the processes and the barriers and facilitators to implementing DCM as a practice development method within formal dementia care settings. PUBMED, PsycINFO, CINAHL, The Cochrane Library-Cochrane reviews, HMIC (Ovid), Web of Science and Social Care Online were searched using the term “Dementia Care Mapping”. Inclusion criterion was primary research studies in any formal dementia care settings where DCM was used as a practice development tool and which included discussion/critique of the implementation processes. Assessment of study quality was conducted using the Mixed Methods Appraisal Tool. Twelve papers were included in the review, representing nine research studies. The papers included discussion of various components of the DCM process, including mapper selection and preparation; mapping observations; data analysis, report writing and feedback; and action planning. However, robust evidence on requirements for successful implementation of these components was limited. Barriers and facilitators to mapping were also discussed. The review found some consensus that DCM is more likely to be successfully implemented if the right people are selected to be trained as mappers, with appropriate mapper preparation and ongoing support and with effective leadership for DCM within the implementing organization/unit and in organizations that already have a person-centered culture or ethos. Future development of the DCM tool should consider ways to save on time taken to conduct DCM cycles. More research to understand the ingredients for effective DCM implementation is needed.
... The reported challenges concerned the implementation of DCM in practice and its further implementation through the organisations. This confirms findings of Van de Ven (2014) and Quasdorf et al. (2017) in their studies on the implementation DCM for people with dementia (without ID) (Quasdorf et al., 2017;Van de Ven, 2014). We found the DCM-in-ID implementation protocol helpful for implementing DCM in the 12 group homes with varying cultures, team characteristics, and habits in care, even though the protocol needs some further tailoring to ID-care. ...
... The reported challenges concerned the implementation of DCM in practice and its further implementation through the organisations. This confirms findings of Van de Ven (2014) and Quasdorf et al. (2017) in their studies on the implementation DCM for people with dementia (without ID) (Quasdorf et al., 2017;Van de Ven, 2014). We found the DCM-in-ID implementation protocol helpful for implementing DCM in the 12 group homes with varying cultures, team characteristics, and habits in care, even though the protocol needs some further tailoring to ID-care. ...
... The success of implementation was dependent on the commitment of staff and managers and the presence of a staff member or manager with a leading role. Previous research of DCM concluded that to reach optimal results, the implementation and fulfilling of preconditions (such as commitment and a personcentred care compliant vision) require strong and accurate attention (Brownie & Nancarrow, 2013;Chenoweth et al., 2015;Dichter, 2015;Jaycock et al., 2006;Jeon et al., 2012;Quasdorf et al., 2017;Rokstad, Vatne, Engedal, & Selbaek, 2015). Adequate realisation of the preconditions should be considered before implementing DCM, to avoid the Type III error for undermining the credibility of an intervention by a poor delivery (Hulscher, Laurant, & Grol, 2005;Moniz-Cook et al., 2008). ...
Introduction: The aging of the population with intellectual disability (ID), with associated conseqences as dementia, creates a need for evidence-based methods to support staff. Dementia Care Mapping (DCM) is perceived to be valuable in dementia care and promising in ID-care. The aim of this study was to evaluate the process of the first use of DCM in ID-care.
Methods: DCM was used among older people with ID and care-staff in 12 group homes of six organisations. We obtained data on the first use of DCM in ID-care via focus-group discussions and face-to-face interviews with: care-staff (N = 24), managers (N = 10), behavioural specialists (N = 7), DCM-ID mappers (N = 12), and DCM-trainers (N = 2). We used the RE-AIM framework for a thematic process-analysis.
Results: All available staff (94%) participated in DCM (reach). Regarding its efficacy, staff considered DCM valuable; it provided them new knowledge and skills. Participants intended to adopt DCM, by continuing and expanding its use in their organisations. DCM was implemented as intended, and strictly monitored and supported by DCM-trainers. As for maintenance, DCM was further tailored to ID-care and a version for individual ID-care settings was developed, both as standards for international use. To sustain the use of DCM in ID-care, a multidisciplinary, interorganisational learning network was established.
Conclusion: DCM tailored to ID-care proved to be an appropriate and valuable method to support staff in their work with aging clients, and it allows for further implementation. This is a first step to obtain an evidence-based method in ID-care for older clients.
... For our trial and the study by van de Ven (2013), process evaluation data are available for further interpretation of the caregiver results. Both process evaluations demonstrated a substantial variation across the participating NH units in adherence to the intervention protocol ( Van de Ven et al., 2014;Quasdorf et al., 2017). In particular, deviations in the integration of action planning (component 5) into daily care practice were common. ...
... Accounting for the overall and specific conditions of a given sample within the implementation strategy will increase intervention adherence and thereby the potential for a significant positive effect of DCM. Moreover, both process evaluations demonstrated the need to outline predefined selection criteria for DCM mappers (Quasdorf, 2017). Selecting caregivers with competencies as change agents, with experience in leadership and with a high level of knowledge of dementia care will improve the consistency of the entry level competences of trainees (Van de Ven et al., 2014) and their potential as champions (Quasdorf et al., 2017). ...
... Moreover, both process evaluations demonstrated the need to outline predefined selection criteria for DCM mappers (Quasdorf, 2017). Selecting caregivers with competencies as change agents, with experience in leadership and with a high level of knowledge of dementia care will improve the consistency of the entry level competences of trainees (Van de Ven et al., 2014) and their potential as champions (Quasdorf et al., 2017). In addition to the importance of mapper competencies, Rokstad et al. (2013) stated that team leaders of NH units should be active role models with a clear vision. ...
Background
The Dementia Care Mapping (DCM) method is an internationally recognized complex intervention in dementia research and care for implementing person-centered care. The Leben-QD II trial aimed to evaluate the effectiveness of DCM with regard to caregivers.
Methods
The nine participating nursing home units were allocated to three groups: (1) DCM method experienced ≥ 1 year, (2) DCM newly introduced during this trial, and (3) regular rating of residents’ quality of life (control group). Linear mixed models were fit to cluster-aggregated data after 0, 6, and 18 months, adjusting for repeated measurements and confounders. The primary outcome was the Approaches to Dementia Questionnaire (ADQ) score; the secondary outcomes were the Copenhagen Psychosocial Questionnaire (COPSOQ) and the Copenhagen Burnout Inventory (CBI).
Results
The analysis included 201 caregivers with 290 completed questionnaires (all three data collection time points). The ADQ showed a significant time and time*intervention effect. At baseline, the estimated least-square means for the ADQ were 71.98 (group A), 72.46 (group B), and 71.15 (group C). The non-linear follow-up of group A indicated an estimated-least square means of 69.71 ( T1 ) and 68.97 ( T2 ); for group B, 72.80 ( T1 ) and 72.29 ( T2 ); and for group C, 66.43 ( T1 ) and 70.62 ( T2 ).
Conclusions
The DCM method showed a tendency toward negatively affecting the primary and secondary outcomes; this finding could be explained by the substantial deviation in adherence to the intervention protocol.
... For our trial and the study by van de Ven (2013), process evaluation data are available for further interpretation of the caregiver results. Both process evaluations demonstrated a substantial variation across the participating NH units in adherence to the intervention protocol ( Van de Ven et al., 2014;Quasdorf et al., 2017). In particular, deviations in the integration of action planning (component 5) into daily care practice were common. ...
... Accounting for the overall and specific conditions of a given sample within the implementation strategy will increase intervention adherence and thereby the potential for a significant positive effect of DCM. Moreover, both process evaluations demonstrated the need to outline predefined selection criteria for DCM mappers (Quasdorf, 2017). Selecting caregivers with competencies as change agents, with experience in leadership and with a high level of knowledge of dementia care will improve the consistency of the entry level competences of trainees ( Van de Ven et al., 2014) and their potential as champions (Quasdorf et al., 2017). ...
... Moreover, both process evaluations demonstrated the need to outline predefined selection criteria for DCM mappers (Quasdorf, 2017). Selecting caregivers with competencies as change agents, with experience in leadership and with a high level of knowledge of dementia care will improve the consistency of the entry level competences of trainees ( Van de Ven et al., 2014) and their potential as champions (Quasdorf et al., 2017). In addition to the importance of mapper competencies, Rokstad et al. (2013) stated that team leaders of NH units should be active role models with a clear vision. ...
Person-centered care (PCC) is a widely recognized concept in dementia research and care. Dementia Care Mapping (DCM) is a method for implementing PCC. Prior studies have yielded heterogeneous results regarding the effectiveness of DCM for people with dementia (PwD). We aimed to investigate the effectiveness of DCM with regard to quality of life (QoL) and challenging behavior in PwD in nursing homes (NHs).
Leben-QD II is an 18-month, three-armed, pragmatic quasi-experimental trial. The sample of PwD was divided into three groups with three living units per group: (A) DCM applied since 2009, (B) DCM newly introduced during the study, and (C) a control intervention based on a regular and standardized QoL rating. The primary outcome was QoL measured with the Quality of Life-Alzheimer's Disease (QoL-AD) proxy, and the secondary outcomes were QoL (measured with QUALIDEM) and challenging behavior (measured with the Neuropsychiatric Inventory Nursing Home version, NPI-NH).
There were no significant differences either between the DCM intervention groups and the control group or between the two DCM intervention groups regarding changes in the primary or secondary outcomes. At baseline, the estimated least square means of the QoL-AD proxy for groups A, B, and C were 32.54 (confidence interval, hereafter CI: 29.36-35.72), 33.62 (CI: 30.55-36.68), and 30.50 (CI: 27.47-33.52), respectively. The DCM groups A (31.32; CI: 28.15-34.48) and B (27.60; CI: 24.51-30.69) exhibited a reduction in QoL values, whereas group C exhibited an increase (32.54; CI: 29.44-35.64) after T2.
DCM exhibited no statistically significant effect in terms of QoL and challenging behavior of PwD in NHs. To increase the likelihood of a positive effect for PwD, it is necessary to ensure successful implementation of the intervention.
... Although this has been shown to increase mortality since 2005 and there is poor evidence of effectiveness in improving symptoms [12], implementation and provision of evidence-based alternatives such as psychosocial interventions [28] do not appear to be used as a first approach [9,29]. This is partly because implementing evidence-based interventions appears to be complex for healthcare staff, and there is often a lack of knowledge about how to implement interventions in a structured way [30][31][32][33]. ...
... Keywords Implementation science, ERIC, CFIR, Outcomes, Dementia science: facilitators and barriers to implementation [35], strategies to support implementation [32,33], and implementation outcomes [34]. ...
Background Caring for people with dementia is complex, and there are various evidence‐based interventions. However, a gap exists between the available interventions and how to implement them. The objectives of our review are to identify implementation strategies, implementation outcomes, and influencing factors for the implementation of evidence‐based interventions that focus on three preselected phenomena in people with dementia: (A) behavior that challenges supporting a person with dementia in long‐term care, (B) delirium in acute care, and (C) postacute care needs.
Methods We conducted a scoping review according to the description of the Joanna Briggs Institute. We searched MEDLINE, CINAHL, and PsycINFO. For the data analysis, we conducted deductive content analysis. For this analysis, we used the Expert Recommendations for Implementation Change (ERIC), implementation outcomes according to Proctor and colleagues, and the Consolidated Framework for Implementation Research (CFIR).
Results We identified 362 (A), 544 (B), and 714 records (C) on the three phenomena and included 7 (A), 3 (B), and 3 (C) studies. Among the studies, nine reported on the implementation strategies they used. Clusters with the most reported strategies were adapt and tailor to context and train and educate stakeholders. We identified one study
that tested the effectiveness of the applied implementation strategy, while ten studies reported implementation outcomes (mostly fidelity). Regarding factors that influence implementation, all identified studies reported between 1 and 19 factors. The most reported factors were available resources and the adaptability of the intervention. To address dementia‐specific influencing factors, we enhanced the CFIR construct of patient needs and resources to include family needs and resources.
Conclusions We found a high degree of homogeneity across the different dementia phenomena, the evidence‐based interventions, and the care settings in terms of the implementation strategies used, implementation outcomes measured, and influencing factors identified. However, it remains unclear to what extent implementation strategies themselves are evidence‐based and which intervention strategy can be used by practitioners when either the implementation outcomes are not adjusted to the implementation strategy and/or the effects of implementation strategies are mostly unknown. Future research needs to focus on investigating the effectiveness of implementation strategies for evidence‐based interventions for dementia care.
Trial registration The review protocol was prospectively published (Manietta et al., BMJ Open 11:e051611, 2021). Keywords Implementation science, ERIC, CFIR, Outcomes, Dementia
... 2 pharmacological approaches to ADRD care found resident benefits (e.g., reduced frequency of behaviors, use of psychotropic medications) [4,[9][10][11][12][13][14]16]. The team-based approach emphasizes a common understanding of the disease process, resident abilities, and cognitive stages, regardless of job role [10,[17][18][19]. ...
... Historically, off-label antipsychotic medications have been used to manage these symptoms, despite negative side effects and concerns about this approach from the NH stakeholder community (e.g., patient advocates, family, policy makers) [6][7][8]. Prior to the emergence of COVID-19, national initiatives were introduced to reduce off-label medication use and enhance non-pharmacological strategies to manage the sources of the behaviors, optimize care, and enhance the resident's quality of life [4,[8][9][10][11][12][13][14][15]. ...
Background:
The COVID-19 pandemic has underscored the daily challenges nursing home (NH) staff face caring for the residents living with Alzheimer's Disease and Related Dementias (ADRD). Non-pharmacological approaches are prioritized over off-label medication to manage the behavioral and psychological symptoms of ADRD. Yet, it is not clear how to best equip NH staff and families with the knowledge and strategies needed to provide non-pharmacological approaches to these residents.
Methods:
This clustered randomized trial will compare team- and problem-based approaches to non-pharmacological ADRD care. The team-based approach includes core training for all NH staff using a common language and strategies to support continuity and sustainability. The problem-based approach capitalizes on the expertise of the professional healthcare providers to target issues that arise. A convergent mixed methods design will be used to examine (a) comparative effectiveness of the two approaches on long-term NH resident outcomes and (b) whether either approach is protective against the negative consequences of COVID-19. The primary outcome is the percentage of ADRD residents with off-label antipsychotic medication use, which will be evaluated with an intent-to-treat approach. Staff and family caregiver perspectives will be explored using a multiple case study approach.
Conclusion:
This trial will be the first-ever evaluation of team- and problem-based approaches to ADRD care across multiple NHs and geographic regions. Results can provide health system leaders and policymakers with evidence on how to optimize ADRD training for staff in an effort to enhance ADRD care delivery.
... The corresponding process evaluation analysed sampling quality (recruitment and randomisation, reach) and intervention quality (relevance and feasibility, adherence to protocol) [13]. A process evaluation for dementia care mapping in Germany used adherence, dosage, participant responsiveness and quality of delivery as evaluation criteria [14]. The FallDem study evaluated the use of two different types of case conferences via delivery of intervention, response to intervention, recruitment and intervention context [15]. ...
... The process evaluation in intersec-CM is focusing on the intervention itself. Based on further process evaluation designs [10][11][12][13][14][15][16], we defined dimensions and research questions focusing on relevant key actors of the ICM in routine care. ...
Background
In the healthcare system in Germany, different institutions and actors play specific roles in the discharge and transition of patients from hospitals into primary care (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen, Wettbewerb an der Schnittstelle zwischen ambulanter und stationärer Gesundheitsversorgung, 2012). However, there are shortcomings in these intersectoral transitions. Especially in older people with cognitive impairment (PCI), discharge management often lacks coordination and cooperation between healthcare providers. This frequently results in higher rates of unscheduled readmission. The project intersec-CM is a randomised controlled trial (RCT) that aims to explore up to what extent an intersectoral care management (ICM) can improve this transition. This ICM is delivered by nurses with special training in care management. The objective of this paper is to describe a mixed-methods process evaluation of the intersectoral care management intervention and the factors that facilitate and inhibit its implementation.
Methods
Different study designs for process evaluations from previous literature were collected and analysed according to the dimension implementation fidelity, satisfaction with the intervention, feasible transfer into routine care, optimum point of time, frequency and execution of the intervention, and context factors.
Results
The actor-network theory was chosen as the theoretic framework for the process evaluation. Based on this theory, a mixed-methods design was developed to combine and integrate qualitative and quantitative evaluation methods. The qualitative part includes semi-structured interviews using topic guides (phase 1) and later in-depth interviews with narrative portions (phase 3), which will be analysed by using the qualitative content analysis according to Kuckartz. The quantitative survey (phase 2) is conducted with standardised questionnaires.
Discussion
Challenges in data collection include the development of interview guidelines, which require different terminologies depending on every specific actor targeted in the intervention. Conducting the interviews, there is a risk of misunderstanding the older PCI by the interviewer and vice versa. However, the combination of qualitative and quantitative approaches as different techniques of process evaluation may help to capture, integrate and analyse data on different dimensions of the intervention.
Conclusions
The results of our process evaluation may serve as an implementation guideline for intersectoral care management in the German healthcare system. Furthermore, the approach to evaluate the process of a complex intervention in health care for older PCI may serve as a stimulus to broaden the evidence base also of other complex intervention studies to improve health care for this vulnerable group.
The study was ethically approved by the Ethics Committee of the Ernst-Moritz-Arndt University of Greifswald. The study has been registered at the U.S. National Library of Medicine.
Trial registration
ClinicalTrials.gov NCT03359408 . Registered on 2 December 2017. The approximate date when recruitment to the process evaluation of the study will be completed is 31 May 2021.
... To begin exploring implementation issues, three recent DCM trials have included a process evaluation [21][22][23], although these have been outside of the UK, focused only on nursing homes with qualified nursing staff, and have involved largely atypical, less challenging implementation approaches. For example, researcher-led implementation, cross-over delivery within one provider organisation and use of sites with prior DCM experience or project coordinators [24]. ...
... The influence of leadership styles, but not their practical features, has been explored in two studies on DCM implementation [23,24]. They found that successful implementation was dependant on clear leadership support by managers who were situationally present and thus engaged with their staff teams, care practices and the intervention, enabling them to tackle implementation barriers [22]. More widely, other leadership-focused studies in care homes and other care settings indicate that leadership styles and culture influence the implementation of changes in care practices [35][36][37]. ...
Background:
Many people with dementia live in care homes, where staff can struggle to meet their complex needs. Successful practice improvement interventions in these settings require strong managerial support, but little is known about how managers can support implementation in practice, or what factors support or hinder care home managers in providing this support. Using Dementia Care Mapping™ (DCM) as an example, this study explored how care home managers can support the implementation of complex interventions, and identified factors affecting their ability to provide this support.
Methods:
We undertook interviews with 48 staff members (managers and intervention leads) from care homes participating in the intervention arm of the DCM EPIC trial of DCM implementation.
Results:
Managerial support played a key role in facilitating the implementation of a complex intervention in care home settings. Managers could provide practical and financial support in many forms. However, managerial support and leadership approaches towards implementation were highly variable in practice, and implementation was easily de-stabilised by management changes or competing managerial priorities. How well managers understood, valued and engaged with the intervention, alongside the leadership style they adopted to support implementation, were key influences on implementation success.
Conclusions:
For care home managers to effectively support interventions they must fully understand the proposed intervention and its potential value. This is especially important during times of managerial or practice changes, when managers lack the skills required to effectively support implementation, or when the intervention is complex. It may be unfeasible to successfully implement new interventions during times of managerial or practice instability.
Trial registration:
Current Controlled Trials ISRCTN82288852 , registered 16/01/2014.
... Further, there have been reviews internationally to reflect on the implementation of person-centered intervention aspects in nursing homes, concluding that a successful implementation of personcentered care remains challenging and is associated with different prerequisites and contextual conditions [15,16]. Nevertheless, studies on the implementation of person-centered intervention aspects in German nursing homes are limited: a mini intervention to use information about meaningful situations in planning and providing care [17], dementia care mapping [18], dementia-specific case conferences [19] and experts in person-centered care for the elderly [20]. Next to that, few international studies have investigated how dementia-specific care is currently provided and organized in nursing homes and which problems are associated with that [21,22]. ...
Background
To ensure high-quality care for residents living with dementia, recommendations for dementia-specific care do exist internationally as well as in Germany. Nevertheless, it remains unclear how dementia-specific care is currently provided and what can be derived from this for the improvement of dementia-specific care. Therefore, this study aimed to investigate the provision of dementia-specific care and related problems in German nursing homes.
Methods
We used a holistic multiple case design with a total of four cases. The cases were defined as care units in which residents living with dementia were cared for. For data collection, we used problem-centered face-to-face interviews, document analysis, and context questionnaires and analyzed all qualitative data inductively and deductively using content structuring qualitative analysis. To identify case-specific and cross-case patterns and themes, we focused on similarities and differences between the cases. The reporting followed the EQUATOR reporting guideline for organizational case studies.
Results
We interviewed 21 professionals, 14 relatives and 8 residents living with dementia. Despite context-specific differences, we identified a variation of care practices and problems in applying person-centered, dementia-specific care in German nursing homes. In all cases, these belong to the following topics: 1) handling neuropsychiatric symptoms, 2) dealing with communication difficulties, 3) providing person-centered interaction and communication, 4) dealing with stress caused by experiencing dementia-specific symptoms and 5) using and sharing knowledge. Even though the problems were identified in all cases, we also found differences in the extent and perception of these problems across the analyzed cases.
Discussion
Despite existing conceptual recommendations and described care practices in our study, the identified problems showed that current care practices are perceived as problematic and partly are not person-centered. This highlights that person-centered requirements in dementia-specific care are not yet adequately addressed and that there is a need to give greater consideration to the identified problems when developing interventions to improve quality of care. Furthermore, the identified context-specific differences in the extent and perception of these problems show that the designs of new care models should allow for more flexibility, so that written recommendations can be implemented in practice and adapted to given contexts.
... Numerous studies have explored experiences of institutional care providers adopting a PCC approach for PLWD in Europe and North America, regarding PCC as a crucial element in the care and interventions [11]. However, they have focused more on specific programs at the individual level (e.g., life stories) [12] or at organizational-level changes (including therapeutic environments) [13,14], and less on real scenarios of PCC in daily care at the intra-individual, inter-individual, and organizational levels. Despite recommendations to implement PCC for PLWD across all care settings [15], its practical application in daily care is still limited. ...
Background
To explore the response and management experiences of nurses and nurse aides in dementia special care units when caring for residents with sundown syndrome based on the person-centered care model.
Methods
Focus group interviews were conducted among nurses and nurse aides from four dementia special care units that have been accredited by the Ministry of Health and Welfare in Taiwan. Content analysis was used for data analysis.
Results
The 29 nurses and nurse aides were recruited to participate in the study. Analysis of interview content revealed six themes, identifying the intra-individual, inter-individual, and organizational dimensions. The central topic was commitment. Under the umbrella of commitment, six themes including self-preparation, non-suppression, diversion, pacification, continuity of meeting, and collaboration, which had 18 subthemes, emerged as responsive care practices for person-centered care when supporting residents with sundown syndrome.
Conclusions
The findings provide responsive care practices based on person-centered care for people living with dementia who develop sundown syndrome. The study can inform practices for quality of care for dementia in long-term care institutions and contribute to the development of materials for nursing training and education.
... The theoretical basis and sub-elements of PCC, the intervention framework and contents are very diverse in each literature, and the interventions using the concept of PCC are very diverse and their evaluation is also diverse [3][4][5][6][7][8][9][10][11]. However, the common focus of all PCCs is the individual person's expectations, needs, wishes, and preferences beyond the medical condition [12]. ...
Abstract Background As many older people spend their time in residential care facilities, the demand for person-centered care (PCC), which affects their quality of life, is increasing. Many residential care facility residents have cognitive problems, such as dementia and strokes. Providing quality care upholds their rights as human beings. Currently, the PCC tools used in South Korea are only translations of foreign tools into Korean, so it is necessary to develop tools for older adult care facilities that reflect the reality of Korean care facilities for older adults. This study aims to develop a tool for measuring PCC in residential care facilities for older people from the perspectives of care givers. Methods The draft of 34 questions was developed through literature reviews, interviews with LTC practitioners and researchers. This developed questionnaire was then administered to 402 direct caregivers working in the residential care facilities because many of the residents had cognitive problems. By measuring the interrater reliability, the items with high levels of agreement were selected and the validity of the construct was checked through factor analysis. To determine whether the domains adequately measured each concept, we calculated correlation coefficients and Cronbach’s α. Results Four domains and 32 items concerning service conditions, resident’s right to self-determination, a comfortable living environment for all residents, and resident and staff satisfaction are derived, thus explaining 24.7%, 23.6%, 14.6%, and 8.00% of the total variance, respectively. Cronbach’s alphas for each domain are 0.965, 0.948, 0.652, and 0.525, respectively, thus demonstrating internal consistency. The inter-rater agreement is high (66.7%~100.0%). The correlation between service conditions and resident’s right to self-determination (r = 0.643, p
... • Person-centred care concepts are promising to meet the needs of PwCI [4]. Implementing personcentred care is challenging, with local change agents considered essential for the implementation process [5][6]. • This role can be performed within the context of expanded nursing practice. ...
Background: The prevalence of people with cognitive impairment (PwCI) in hospital varies between 11 and 55 %. Person-centred care concepts are promising to meet the needs of PwCI. Implementing person-centred care is challenging, with local change agents considered essential for the implementation process. This role can be performed within the context of expanded nursing practice. The ENROLE-acute project aims to develop, implement and evaluate a complex person-centred care intervention with expanded practice nurses (EPNs) in acute hospitals.
Purpose: The aim is to describe the expanded roles and tasks of nurses in caring for PwCI and their relatives in acute hospitals to support the development of the EPN role for ENROLE-acute.
Methods: A Systematic Review of international literature is conducted, searching MEDLINE, CINAHL, Cochrane Library, Web of Science, ALOIS and Livivo without time limit. Original research studies are included at all levels of expanded nursing practice, from nurse-led concepts to roles and tasks within Advanced Nursing Practice (ANP). Quality appraisal is conducted by using the CASP tool. Data is extracted using the TIDieR checklist and clustered according to the competencies of the Hamric Model of ANP.
Results: The review is currently in the data extraction and analysis phase. 39 references were identified. Interim results from 29 studies show tasks in all competence areas of the Hamric model. A core component of EPN’s clinical practice is the assessment of cognitive impairment, taking on executive, guiding and advisory roles (15 reports). In addition, conducting training for staff (15 reports) and coaching patients and relatives (10 reports) and consultation (7 reports) are reported. Clinical leadership is evident in the context of monitoring staff (11 reports), developing and collaborating on procedural guidelines (6 reports) and coordinating interdisciplinary rounds (3 reports). Collaboration is carried out with other professional groups (6 reports), nursing staff (11 reports) and primary care clinicians (7 reports). Tasks related to ethical decision-making and research are rarely reported.
Conclusion / Significance: The results provide an overview of roles and tasks of EPNs in the care of PwCI. The heterogeneity of the different levels of EPNs is reflected in the identified tasks. Comparably lower levels of expanded nursing practice can be applied to the early stage of ANP development in Germany. The results are discussed and prioritised in participatory expert workshops to adapt the EPN’s roles for PwCI to the German context.
... The finding that leading staff endorse DeCM gives reason for optimism in the light of other studies on the implementation success of dementia care interventions. For it has been demonstrated that positive attitudes and active leadership involvement in implementation were proven to be associated with implementation success [26,33]. The numerous local initiatives, alliances, and committed, highly connected key players are very important factors in the implementation process. ...
Dementia is a leading cause of disability and dependency in older people worldwide. As the number of people affected increases, so does the need for innovative care models. Dementia care management (DCM) is an empirically validated approach for improving the care and quality of life for people with dementia (PwD) and caregivers. The aim of this study is to investigate the influencing factors and critical pathways for the implementation of a regionally adapted DCM standard in the existing primary care structures in the German region of Siegen-Wittgenstein (SW). Utilizing participatory research methods, five local health care experts as co-researchers conducted N = 13 semi-structured interviews with 22 local professionals and one caregiver as peer reviewers. Data collection and analysis were based on the Consolidated Framework for Implementation Research (CFIR). Our results show that among the most mentioned influencing factors, three CFIR constructs can be identified as both barriers and facilitators: Patients’ needs and resources, Relative advantage, and Cosmopolitanism. The insufficient involvement of relevant stakeholders is the major barrier and the comprehensive consideration of patient needs through dementia care managers is the strongest facilitating factor. The study underlines the vital role of barrier analysis in site-specific DCM implementation.
... Other studies have noted that negative leadership characteristics -such as an absence of engagement with (and support to) care staff, the adoption of top-down hierarchical reporting structures, the poor management of staff relationships and communication, and the lack of promotion of a personalised care culture -acted as barriers to the effective delivery of personalised care (Rokstad et al, 2015;Quasdorf et al, 2016;Jacobsen et al, 2017;Griffiths et al, 2019). Similarly, a lack of management feedback, supervision, incentives, role modelling and positive reinforcement was associated with a poor understanding of, and lack of interest in, personalised care principles among care staff (Argyle and Kelly, 2015;Chenoweth et al, 2015). ...
The personalisation of residential care services is based on three broad principles of valuing personal identity, empowering resident decision-making and fostering care relationships. We analysed 50 Care Quality Commission care home inspection reports to identify factors that the reports indicate facilitate or hinder the delivery of personalised residential care in England. Findings suggest that the provision of personalised services is affected by staff skills, attitudes and availability, as well as the quality of care home leadership. Future care policy should consider addressing external pressures facing the care home sector, including inadequate funding and too few staff, to mitigate barriers to delivering high-quality, personalised care.
... Following this, the lack of research on the organizational preconditions for the implementation of these interventions could be an additional reason why we found heterogeneous and inconsistent results. 63,64 In the included studies, it seems unknown whether the respective intervention was implemented successfully and how success was determined. As a result, it remains unclear whether an intervention had no effect or whether implementation of the intervention was unsuccessful. ...
Objectives: The objective of the present systematic review was to investigate the effects of organizational capacity building interventions on the environment, nursing staff capacity and mobility of residents in nursing facilities.
Design: Systematic review
Setting and Participants: Nursing facilities, staff and residents.
Methods: We conducted a systematic review according to the methods of the Cochrane Collaboration. The systematic review was prospectively registered in the PROSPERO database of systematic reviews (registration number CRD42020202996). We searched for studies in MEDLINE (via PubMed), CINAHL (via EBSCO), the Physiotherapy Evidence Database (PEDro) and the Cochrane Library (07/20). A narrative synthesis was conducted because of the high heterogeneity of the included studies.
Results: We identified 6747 records and included 14 studies in our review. We clustered the 14 interventions into three different categories (environmental modification, nursing staff capacity, and multifactorial interventions). Three studies assessed outcomes at the nursing staff level, and all studies reported outcomes at the resident level. We found highly heterogeneous/inconsistent effects of organizational capacity building on increasing nursing staff capacity and/or resident mobility.
Conclusions and Implications: The findings emphasize the need for further research focusing on an international understanding and definition of organizational capacity building. Additionally, research and intervention development for organizational capacity building interventions to promote resident mobility are needed while applying the framework of the Medical Research Council. Furthermore, studies should assess outcomes regarding the environment and nursing staff to better understand if and how environmental structures and nursing staff capacity effect resident mobility.
... These interventions have contributed to tackle the belief of considering health organizations as unknown and not friendly environments. Different initiatives have been successfully implemented in North European countries for being inclusive with this population, where laws, policies and strategies to support PwD are stablished [20,21]. In these regions, dementia-friendly hospitals and healthcare centres can be found as an architectonical and cultural adaptation to PwD [22]. ...
People with dementia (PwD) occupy around 25% of the hospital beds. Once PwD are admitted to hospitals, their cognitive impairment is not considered in most of the cases. Thus, it causes an impact on the development of the disease becoming a stressful situation as care plans are not adapted to PwD. The aim of this study was to explore the published core elements when designing a dementia care pathway for hospital settings. A scoping review was conducted to provide an overview of the available research evidence and identify the knowledge gaps regarding the topic. This review highlights person-centered care, compassionate care and end-of-life process as some of the key elements that should integrate the framework when designing a dementia care pathway. Architectonical outdoor and indoor hospital elements have also been found to be considered when adapting the healthcare context to PwD. Findings provide information about the key points to focus on to successfully design dementia interventions in hospital environments within available resources, mostly in those contexts in which national dementia plans are in its infancy. Hospitals should transform their patients’ routes and processes considering the increasing demographic changes of people with cognitive impairment.
... The particular strengths of a qualitative process evaluation are that it contributes to understanding social processes that occurred during implementation [27], helps explain when observed outcomes are divergent from expected outcomes, and sheds light on contextual factors that influenced the implementation and may have led to variations in effectiveness [28]. The Grant et al. framework was supplemented by the Consolidated Framework for Implementation Research (CFIR) [29] as analytical framework, which has been used in implementation research and process evaluations [30][31][32][33], to introduce a clear focus on factors that influenced the implementation process. The CFIR represents a consolidation of major implementation theories, providing consistent definitions of concepts. ...
Background: Dementia is regularly associated with behavioral and psychological symptoms of dementia (BPSD, also referred to as challenging behavior). Structured dementia-specific case conferences (DSCCs) enable nursing staff in nursing homes (NHs) to analyze and handle the BPSD of residents with dementia. The FallDem trial estimated the effectiveness of the structured DSCC intervention WELCOME-IdA (Wittener model of case conferences for people with dementia – the Innovative dementia-oriented Assessment tool) in NHs in Germany. No significant change in the overall prevalence of challenging behavior was found. A multipart process evaluation was conducted to explain this result.
Methods: This qualitative process evaluation of the response of individuals, perceived maintenance, effectiveness, and unintended consequences was part of the multipart process evaluation that followed the framework by Grant et al. (Trials 14: 15, 2013). It used the data from semi-structured telephone interviews and focus group interviews with nurses and managers as secondary data. Selected domains of the Consolidated Framework for Implementation Research (CFIR) were used as deductive categories for a directed content analysis.
Results: The interviewees in all NHs appraised WELCOME-IdA as generating positive change, although it proved important that some adjustments were made to the intervention and the organization. Thirteen CFIR constructs out of the domains intervention characteristics, inner setting, and process proved to be essential for understanding the different course that the implementation of WELCOME-IdA took in each of the four NHs. This is reflected in three types of WELCOME-IdA implementation: (1) priority on adjusting the intervention to fit the organization, (2) priority on adjusting the organization to fit the intervention, and (3) no setting of priorities in adjusting either the organization or the intervention.
Conclusion: The unsatisfying results of the FallDem effectiveness trial can in part be explained with regard to the interplay between the intervention and the implementation which was revealed in the processes that occurred in the organizations during the implementation of the WELCOME-IdA intervention. Future implementation of WELCOME-IdA should be tailored based on an analysis of the organization’s readiness, resources, and capacities and should also define custom-made intervention and implementation outcomes to measure success. Furthermore, our results confirm that the CFIR can be used beneficially to conduct process evaluations.
... These interventions have contributed to tackle the stigma of health organizations as unknown and dangerous environments. Different dementia-friendly environment initiatives have been successfully implemented in regions known for being sensitive with this population as it is the case of North European, North American and Canadian countries where several norms, laws, policies and strategies to support people living with dementia are established (Quasdorf et al., 2017;Biglieri, 2018). Furthermore relevant studies have been published where people living with dementia and healthcare staff are included in decision-making about dementia hospitals adaptations (Hung et al., 2017;Hung, Son & Hung, 2019;Clifford & Doody, 2018). ...
People with dementia occupy 25% of the hospital beds. When they are admitted to hospitals their cognitive impairment is not considered in most of the cases. Some European and North American countries already have experience of implementing national plans about Alzheimer’s disease and dementia. However South European countries such as Spain are in the early stages. The aim of this study is to design an Integrated Care Pathway to adapt the hospital environment and processes to the needs of people with dementia and their caregivers, generating a sense of confidence, increasing their satisfaction and protecting them from potential harmful situations. This study uses King’s Fund Dementia Tool to assess the hospital environment and develop a continous improvement process. People with dementia, families, caregivers and healthcare staff will evaluate the different settings in order to provide guidance based on patient needs. Person-centred care, prudent healthcare and compassionate care are the conceptual framework of this care pathway. The implementation and evaluation of this research protocol will provide information about how to successfully design dementia interventions in a hospital environment within available resources in those contexts where dementia plans are in its infancy, as only around 15% of all states worldwide have currently designed a concise dementia national plan.
... Despite DCM's widespread and long-term use in care home settings, there remains limited formal exploration of the process of its implementation in practice [21]. Only two previous controlled studies of DCM, have included a process evaluation [20,22], to qualitatively explore implementation and fidelity. Both used the staff-led model of DCM implementation and found implementation issues within some care home sites. ...
Background
Dementia Care Mapping™ (DCM) is a widely used, staff-led, psychosocial intervention to support the implementation of person-centred care. Efficacy evaluations in care homes have produced mixed outcomes, with implementation problems identified. Understanding the experiences of staff trained to lead DCM implementation is crucial to understanding implementation challenges, yet this has rarely been formally explored. This study aimed to examine the experiences of care home staff trained to lead DCM implementation, within a large cluster randomised controlled trial.
Methods
Process evaluation including, semi-structured interviews with 27 trained mappers from 16 intervention allocated care homes. Data were analysed using template variant of thematic analysis.
Results
Three main themes were identified 1) Preparedness to lead - While mappers overwhelmingly enjoyed DCM training, many did not have the personal attributes required to lead practice change and felt DCM training did not adequately equip them to implement it in practice. For many their expectations of the mapper role at recruitment contrasted with the reality once they began to attempt implementation; 2) Transferring knowledge into practice – Due to the complex nature of DCM, developing mastery required regular practice of DCM skills, which was difficult to achieve within available time and resources. Gaining engagement of and transferring learning to the wider staff team was challenging, with benefits of DCM largely limited to the mappers themselves, rather than realised at a care home level; and 3) Sustaining DCM - This required a perception of DCM as beneficial, allocation of adequate resources and support for the process which was often not able to be provided, for the mapper role to fit with the staff member’s usual duties and for DCM to fit with the home’s ethos and future plans for care.
Conclusions
Many care homes may not have staff with the requisite skills to lead practice change using DCM, or the requisite staffing, resources or leadership support required for sustainable implementation. Adaptations to the DCM tool, process and training may be required to reduce its complexity and burden and increase chances of implementation success. Alternatively, models of implementation not reliant on care home staff may be required.
... Cooney et al. (2014) and Eritz et al. (2016) examine the challenges in offering choices to residents with advanced dementia and multiple co-morbidities who may be less able to relay their personal history and express their wishes. Finally, several studies suggest that some of the difficulties care staff face include building close relationships with residents and learning how to fulfil their wishes when working in care homes affected by heavy workloads, high staff turnover and critical time constraints Quasdorf et al. 2017, Simmons et al. 2018). Stevens et al. (2011) dissected the difficulties of incorporating ' choice' into a public care system, using Clarke et al.'s (2008) "antagonisms of choice" framework. ...
Context: Direct payments (DP) – cash for care – have been promoted in England as a mechanism to enhance the choice and control of service users living in community settings who are eligible for state-funded care. In 2011, the government decided to pilot DPs in residential care in a few areas and to commission an evaluation of the pilot programme. Objective: To explore the experiences of care home residents and their families offered a DP, in terms of choice of and control over their care and of their consumer power in local care home markets. Methods: We held 34 semi-structured interviews with care home residents and family members as part of the evaluation. Interviews were analysed using the “Antagonisms of Choice” framework to study the frictions caused by promoting self-directed care via private market mechanisms within publicly funded systems. Findings: Findings suggest unequal access to DPs according to residents’ access to family networks, level of cognitive function and underlying physical health. Some participants expressed concern about the effects of DPs on quality of care home services. Several family members using DPs perceived enhanced power in relation to the care providers; others saw no benefit from DPs. Limitations: Uptake of DPs was lower than expected, potentially limiting the generalisability of these findings.
... The framework of patient-centredness includes six domains of activities: patient information; patient involvement in care; involvement of family and friends; patient empowerment; physical support and emotional support (Scholl 2014). In line with the theoretical heterogeneity, the theoretical foundation and intervention components also differ among person-cen- The implementation of person-centred care is challenging ( Quasdorf 2017). Individual training of caregivers with reference to person-centred care skills is not enough. ...
... The efficacy of person-centred interventions can be largely dependent upon organisational factors external to the intervention itself such as leadership, managerial practice, staff empowerment and resident engagement (Hebblethwaite, 2013;Rapaport et al., 2017). This is partly due to the impact these organisational factors have on the implementation process of personcentred care, such as dementia care mapping, when used as a tool to facilitate practice development (Quasdorf et al., 2017;Surr et al., 2018). The literature base around the style and impact of macro organisational factors will therefore now be reviewed. ...
This thesis addresses the challenges associated with the implementation of models of person-centred care in newly operational care homes in an English context. This study critically evaluates a model of care produced in house, with academic support named in this thesis as EMBRACELIFE. The implementation of person-centred care in newly opened care settings is yet to be explored. Data collection took place between September and November 2015. An ethnographic approach was taken to fieldwork. Semi-structured interviews and/or unstructured observations were conducted with 20 care workers and 10 people with dementia. Document analysis was also undertaken on 6 personal care plans. A letter from the care provider completed the data set. A thematic approach to data collection was undertaken, informed by principles of discourse analysis. The finding revealed a culture of care organised around task. Overarching themes indicative of task-based practice were the care planning, activity, outdoor space, care worker perceptions, the mealtime experience, leadership and a lack of choice. The model of care was therefore not fully implemented. The research indicated the implementation process was hindered by organisational issues. These were inadequate staff training, unmet staff expectations, low staff satisfaction, a lack of a team ethos, a high agency staff presence, a lack of flexible care delivery. The newly operational status of the home had a uniquely mediating influence on these findings due to the challenge of assembling a new staff team, having a domino effect on the organisational issues described. This thesis concludes by suggesting care providers are in need of more support if they are to overcome organisational barriers, accentuated by the challenges of opening a new care home, to achieve person-centred cultures of care in such settings.
... Another important aspect is that the effectiveness of management studies largely depends on the skill and motivation of the staff and thus affected by selection bias. The successful implementation of DCM, for example, requires well-functioning networks, highly trained staff, a dementia friendly environment and flexible organisational structure [75]. The advocates of DCM have an emphasis on the implementation of DCM in nursing home care with adequate training for the nursing home staff to have a health effect first and then the economic evaluations can be performed. ...
Objective: The objective is to systematically review the literature on economic evaluations of the interventions for the management of dementia and Alzheimer patients in home, hospital or institutional care. Methods: A systematic search of published economic evaluation studies in English was conducted using specified key words in relevant databased and websites. Data extracted included methods and empirical evidence (costs, effects, incremental cost-effectiveness ratio) and we assessed if the conclusions made in terms of cost-effectiveness were supported by the reported evidence. The included studies were also assessed for reporting quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Results: Twelve studies were identified and there was a considerable heterogeneity in methodological approaches, target populations, study time frames, and perspectives as well as types of interventions. Interventions for the management of dementia patients are in general, not cost-effective. Interventions at the community and home setting for managing both the dementia patients and caregivers on a large scale may have the potential to save societal resources. Conclusion: More effectiveness studies as well as good quality economic evaluations are required before implementation decisions on management strategies can be made based on cost-effectiveness.
... Several studies of DCM in nursing home settings reported difficulties similar to ours in fulfilling the DCM-preconditions. These studies concluded that to reach optimal effect of DCM, the implementation requires strong and accurate attention (Brownie & Nancarrow, 2013;Chenoweth et al., 2015;Dichter et al., 2015;Jaycock et al., 2006;Jeon et al., 2012;Quasdorf et al., 2017;Rokstad, Vatne, Engedal, & Selbaek, 2015;Van de Ven, 2014). Increasing the number of realized preconditions is likely to increase the success of the implementation (Chenoweth et al., 2015;Rokstad et al., 2015;Van de Ven et al., 2013). ...
The number of people with intellectual disability and dementia increases; this combination causes behavioural changes. Dementia Care Mapping (DCM) supports staff in dementia care in nursing homes and may be useful in intellectual disability‐care. This qualitative study examines the feasibility of DCM for older people with intellectual disability and dementia.
The present authors obtained data in focus groups and interviews with professional users and analysed using a framework for feasibility studies. With experts in dementia and intellectual disability researches, the present authors determined the overall feasibility.
DCM was found to be feasible in intellectual disability‐care, regarding five domains of feasibility. Staff reported DCM to be useful and valuable and addresses to their demand for skills and knowledge. All professional users found DCM feasible in intellectual disability‐care, which was confirmed by experts.
DCM is feasible in intellectual disability‐care. When fully tailored to intellectual disability‐care, DCM is useful and provides opportunities to assess its effectiveness.
Background
Living Labs, as a type of academic-practice partnerships, possess the potential to transform care and research into a participatory partnership and narrow the research-practice gap to improve evidence-based and Person-centred care. Given the lack of systematic investigations of Living Labs in healthcare, we will establish a dementia-specific academic-practice partnership (Living Lab Dementia) in Germany and conduct a process evaluation. The aim of this study is to gain insights into the intervention itself (mechanisms of impact) and its implementation process (degree of implementation, barriers, and facilitators).
Methods
This process evaluation of the multi-center research project PraWiDem (German acronym for linking professional nursing practice and research in dementia) will be conducted applying a convergent mixed methods design and will be based on the Medical Research Council (MRC) framework for the development and evaluation of complex interventions. The intervention is presented in a logic model which describes relevant basic theoretical assumptions, intervention components, implementation aspects, mechanisms of impact, relevant outcomes, and the context in which the intervention is delivered. Data will be collected before the intervention (T0), during the intervention period, and at follow-up after 18 months (T1). Qualitative data will be collected through semi-structured interviews and focus groups. Quantitative data sources will be process documents and questionnaires.
Discussion
Our study will provide important insights into the Living Lab Dementia intervention and its implementation processes. The results of this evaluation will contribute to the refinement of the intervention and its implementation processes, and will enable to measure the impact of these processes in future studies.
Background and objectives:
Person-centred care is the gold standard of care for people living with dementia, yet few systematic reviews have detailed how it is delivered in practice. This mixed-methods review aimed to examine the delivery of person-centred care, and its effectiveness, for people living with dementia in residential aged care.
Research design and methods:
A systematic review and meta-analysis. Eligible studies were identified across four databases. Quantitative and qualitative studies containing data on person-centred care delivered to people with dementia living in residential aged care were included. Meta-analysis using a random effects model was conducted where more than three studies measured the same outcome. A narrative meta-synthesis approach was undertaken to categorise verbatim participant quotes into representative themes. Risk of bias was undertaken using quality appraisal tools from the Joanna Briggs Institute.
Results:
Forty-one studies were identified for inclusion. There were 34 person-centred care initiatives delivered, targeting 14 person-centred care outcomes. Three outcomes could be pooled. Meta-analyses demonstrated no reduction in agitation (standardised mean difference -0.27, 95% CI -0.58, 0.03), improvement in quality of life (standardised mean difference -0.63, 95% CI -1.95, 0.70), or reduced neuropsychiatric symptoms (mean difference -1.06, 95% CI -2.16, 0.05). Narrative meta-synthesis revealed barriers (for example, time constraints) and enablers (for example, staff collaboration) to providing person-centred care from a staff perspective.
Discussion and implications:
The effectiveness of person-centred care initiatives delivered to people with dementia in residential aged care is conflicting. Further high-quality research over an extended time is required to identify how person-centred care can be best implemented to improve resident outcomes.
Resumen
Objetivo
Conocer los elementos que formarían parte de una adecuada asistencia sociosanitaria a personas mayores viviendo en centros residenciales, identificar barreras y facilitadores a dicha asistencia y el papel de la Atención Primaria.
Diseño
Metodología cualitativa con un enfoque fenomenológico.
Emplazamiento
Centro de salud urbano y centro residencial concertado adscrito en la zona sureste de la Comunidad de Madrid.
Participantes
Personas mayores residentes, sus familiares y profesionales de la residencia y del Equipo de Atención Primaria.
Método
Se realizaron 5 grupos focales entre noviembre de 2019 y enero de 2020, con entrevista semiestructurada a partir de las variables de análisis y dimensiones de interés para los objetivos. Las sesiones fueron grabadas y transcritas. Se realizó una codificación abierta y axial para identificar las categorías y una triangulación de los datos.
Resultados
Los elementos de una adecuada asistencia son la atención a la persona, la promoción de la autonomía, la información adecuada a residentes y familiares, la calidad de los servicios, la coordinación entre profesionales y unos cuidados continuos en el final de la vida. Son barreras el déficit de profesionales, las diferencias de expectativas entre usuarios y trabajadores y la brecha organizativa entre el sistema sanitario y la asistencia propia en residencias sanitarizadas. El papel de la Atención Primaria queda definido por su función burocrática.
Conclusiones
Es necesario continuar explorando estos elementos y perfilar el papel de la Atención Primaria en entornos residenciales de diferentes características.
Background
Person-centered care is considered standard care in long-term care for individuals living with dementia. However, qualitative reviews that synthesize the staff experiences of the implementation of person-centered care are lacking.
Objective
This review aims to synthesize the experiences of nursing staff members after the implementation of person-centered care for individuals living with dementia.
Design
A meta-synthesis was conducted.
Data sources
Overall, five electronic databases (i.e., PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, PsycINFO, and Cochrane Library) were searched for the following terms: “dementia,” “person-centered care,” and “qualitative.” The search was limited to articles published in English from January 1998 to December 2021, considering the period when person-centered care was applied in dementia care.
Review Methods
Qualitative content analysis was conducted using a person-centered nursing framework. Meta-data analysis, meta-method, and meta-theory analysis were used to synthesize the results of the included studies by three independent authors. The methodological quality of included studies was assessed using the Critical Appraisal Skills Programme (CASP) tool.
Results
Altogether, 19 studies were included in this review. Through meta-synthesis, 12 themes, including professionally competent, perspective shift, shared decision-making among staff, appropriate supportive system, understanding and respecting individuals living with dementia, interaction with persons living with dementia and their family members, collaboration among staff members, concern about the well-being of an individual living with dementia, meaningful relationship between staff members and individuals living with dementia, quality care, reflections for maintenance, and barriers to overcome, emerged.
Conclusions
A person-centered nursing framework could be implemented in person-centered care for individuals living with dementia. However, the framework should be modified based on the characteristics of individuals living with dementia. Additionally, reflection strategies for maintenance and barriers are added to facilitate successful person-centered care implementation.
Registration
The study was registered with PROSPERO (International prospective register of systematic reviews) in May 2022 (registration number: CRD42022316097).
Background:
Care homes are complex settings to undertake intervention research. Barriers to research implementation processes can threaten studies' validity, reducing the value to residents, staff, researchers and funders. We aimed to (i) identify and categorise contextual factors that may mediate outcomes of complex intervention studies in care homes and (ii) provide recommendations to minimise the risk of expensive research implementation failures.
Methods:
We conducted a systematic review using a framework synthesis approach viewed through a complex adaptive systems lens. We searched: MEDLINE, Embase, CINAHL, ASSIA databases and grey literature. We sought process evaluations of care home complex interventions published in English. Narrative data were indexed under 28 context domains. We performed an inductive thematic analysis across the context domains.
Results:
We included 33 process evaluations conducted in high-income countries, published between 2005 and 2019. Framework synthesis identified barriers to implementation that were more common at the task and organisational level. Inductive thematic analysis identified (i) avoiding procedural drift and (ii) participatory action and learning as key priorities for research teams. Research team recommendations include advice for protocol design and care home engagement. Care home team recommendations focus on internal resources and team dynamics. Collaborative recommendations apply to care homes' individual context and the importance of maintaining positive working relationships.
Discussion:
Researchers planning and undertaking research with care homes need a sensitive appreciation of the complex care home context. Study implementation is most effective where an intervention is co-produced, with agreed purpose and adequate resources to incorporate within existing routines and care practices.
Background
Sleep problems are highly prevalent in people with dementia. Nevertheless, there is no “gold standard” intervention to prevent or reduce sleep problems in people with dementia. Existing interventions are characterized by a pronounced heterogeneity as well as insufficient knowledge about the possibilities and challenges of implementation. The aim of this study is to pilot and evaluate the effectiveness of a newly developed complex intervention to prevent and reduce sleep problems in people with dementia living in nursing homes.
Methods
This study is a parallel group cluster-randomized controlled trial. The intervention consists of six components: (1) the assessment of established sleep-promoting interventions and an appropriate environment in the participating nursing homes, (2) the implementation of two “sleep nurses” as change agents per nursing home, (3) a basic education course for nursing staff: “Sleep problems in dementia”, (4) an advanced education course for nursing staff: “Tailored problem-solving” (two workshops), (5) workshops: “Development of an institutional sleep-promoting concept” (two workshops with nursing management and sleep nurses) and (6) written information and education material (e.g. brochure and “One Minute Wonder” poster). The intervention will be performed over a period of 16 weeks and compared with usual care in the control group.
Overall, 24 nursing homes in North, East and West Germany will be included and randomized in a 1:1 ratio. The primary outcome is the prevalence of sleep problems in people with dementia living in nursing homes. Secondary outcomes are quality of life, quality of sleep, daytime sleepiness and agitated behavior of people with dementia, as well as safety parameters like psychotropic medication, falls and physical restraints. The outcomes will be assessed using a mix of instruments based on self- and proxy-rating. A cost analysis and a process evaluation will be performed in conjunction with the study.
Conclusions
It is expected that the intervention will reduce the prevalence of sleep problems in people with dementia, thus not only improving the quality of life for people with dementia, but also relieving the burden on nursing staff caused by sleep problems.
Trial registration
Current controlled trials: ISRCTN36015309 . Date of registration: 06/11/2020.
Background
The ageing of people with intellectual disabilities, with associated morbidity like dementia, calls for new types of care. Person‐centred methods may support care staff in providing this, an example being Dementia Care Mapping (DCM). DCM has been shown to be feasible in ID‐care. We examined the experiences of ID‐professionals in using DCM.
Methods
We performed a mixed‐methods study, using quantitative data from care staff (N = 136) and qualitative data (focus‐groups, individual interviews) from care staff, group home managers and DCM‐in‐intellectual disabilities mappers (N = 53).
Results
DCM provided new insights into the behaviours of clients, enabled professional reflection and gave new knowledge and skills regarding dementia and person‐centred care. Appreciation of DCM further increased after the second cycle of application.
Conclusion
DCM is perceived as valuable in ID‐care. Further assessment is needed of its effectiveness in ID‐care with respect to quality of care, staff‐client interactions and job performance.
Exploring how people with MCI or mild dementia perceive the GRADIOR computer cognitive rehabilitation program, as an important measure for the development of this technology focused in the needs of their users.
Background
The implementation of evidence-based interventions for people with dementia is complex and challenging. However, successful implementation might be a key element to ensure evidence-based practice and high quality of care. There is a need to improve implementation processes in dementia care by better understanding the arising challenges. Thus, the aim of this study was to identify recent knowledge concerning barriers and facilitators to implementing nurse-led interventions in dementia care.
Methods
We performed a scoping review using the methodological framework of Arksey and O’Malley. Studies explicitly reporting on the implementation process and factors influencing the implementation of a nurse-led intervention in dementia care were included. We searched eight databases until January 2019. Two authors independently selected the studies. For data analysis, we used an inductive approach to build domains and categories.
Results
We included 26 studies in the review and identified barriers as well as facilitators in five domains: policy (e.g. financing issues, health insurance), organisation (e.g. organisational culture and vision, resources, management support), intervention/implementation (e.g. complexity of the intervention, perceived value of the intervention), staff (e.g. knowledge, experience and skills, attitude towards the intervention), and person with dementia/family (e.g. nature and stage of dementia, response of persons with dementia and their families).
Conclusions
Besides general influencing factors for implementing nursing interventions, we identified dementia-specific factors reaching beyond already known barriers and facilitators. A pre-existing person-centred culture of care as well as consistent team cultures and attitudes have a facilitating effect on implementation processes. Furthermore, there is a need for interventions that are highly flexible and sensitive to patients’ condition, needs and behaviour.
Background The implementation of evidence-based interventions for people with dementia is complex and challenging. However, successful implementation might be a key element to ensure evidence-based practice and high quality of care. There is a need to improve implementation processes in dementia care by better understanding the arising challenges. Thus, the aim of this study was to identify recent knowledge concerning barriers and facilitators to implementing nurse-led interventions in dementia care. Methods We performed a scoping review using the methodological framework of Arksey and O’Malley. Studies explicitly reporting on the implementation process and factors influencing the implementation of a nurse-led intervention in dementia care in all settings were included. We searched eight databases from January 2015 until January 2019. Two authors independently selected the studies. For data analysis, we used an inductive approach to build domains and categories. Results We included 26 studies in the review and identified barriers as well as facilitators in five domains: policy (e.g. financing issues, health insurance), organisation (e.g. organisational culture and vision, resources, management support), intervention/implementation (e.g. complexity of the intervention, perceived value of the intervention), staff (e.g. knowledge, experience and skills, attitude towards the intervention), and person with dementia/family (e.g. nature and stage of dementia, response of persons with dementia and their families). Conclusions Besides general influencing factors for implementing nursing interventions, we identified dementia-specific factors reaching beyond already known barriers and facilitators. A pre-existing person-centred culture of care as well as consistent team cultures and attitudes have a facilitating effect on implementation processes. Furthermore, there is a need for interventions that are highly flexible and sensitive to patients’ condition, needs and behaviour.
Dementia Care Mapping is an internationally applied method for enhancing person-centred care for people with dementia in nursing homes. Recent studies indicate that leadership is crucial for the successful implementation of Dementia Care Mapping; however, research on this topic is rare. This case study aimed to explore the influence of leadership on Dementia Care Mapping implementation in four nursing homes. Twenty-eight interviews with project coordinators, head nurses and staff nurses were analysed using qualitative content analysis. Nursing homes that failed to implement Dementia Care Mapping were characterised by a lack of leadership. The leaders of successful nursing homes promoted person-centred care and were actively involved in implementation. While overall leadership performance was positive in one of the successful nursing homes, conflicts related to leadership style occurred in the other successful nursing homes. Thus, it is important that leaders promote person-centred care in general and Dementia Care Mapping in particular. Furthermore, different types of leadership can promote successful implementation.
Trial registration of the primary study: Current Controlled Trials ISRCTN43916381.
Implementation fidelity refers to the degree to which an intervention or programme is delivered as intended. Only by understanding and measuring whether an intervention has been implemented with fidelity can researchers and practitioners gain a better understanding of how and why an intervention works, and the extent to which outcomes can be improved.
DISCUSSION: The authors undertook a critical review of existing conceptualisations of implementation fidelity and developed a new conceptual framework for understanding and measuring the process. The resulting theoretical framework requires testing by empirical research.
SUMMARY: Implementation fidelity is an important source of variation affecting the credibility and utility of research. The conceptual framework presented here offers a means for measuring this variable and understanding its place in the process of intervention implementation.
Aims:
We examined whether Dementia Care Mapping (DCM) or the VIPS practice model (VPM) is more effective than education of the nursing home staff about dementia (control group) in reducing agitation and other neuropsychiatric symptoms as well as in enhancing the quality of life among nursing home patients.
Methods:
A 10-month three-armed cluster-randomized controlled trial compared DCM and VPM with control. Of 624 nursing home patients with dementia, 446 completed follow-up assessments. The primary outcome was the change on the Brief Agitation Rating Scale (BARS). Secondary outcomes were changes on the 10-item version of the Neuropsychiatric Inventory Questionnaire (NPI-Q), the Cornell Scale for Depression in Dementia (CSDD) and the Quality of Life in Late-Stage Dementia (QUALID) scale.
Results:
Changes in the BARS score did not differ significantly between the DCM and the control group or between the VPM and the control group after 10 months. Positive differences were found for changes in the secondary outcomes: the NPI-Q sum score as well as the subscales NPI-Q agitation and NPI-Q psychosis were in favour of both interventions versus control, the QUALID score was in favour of DCM versus control and the CSDD score was in favour of VPM versus control.
Conclusions:
This study failed to find a significant effect of both interventions on the primary outcome. Positive effects on the secondary outcomes indicate that the methods merit further investigation.
The effectiveness of dementia-care mapping (DCM) for institutionalised people with dementia has been demonstrated in an explanatory cluster-randomised controlled trial (cRCT) with two DCM researchers carrying out the DCM intervention. In order to be able to inform daily practice, we studied DCM effectiveness in a pragmatic cRCT involving a wide range of care homes with trained nursing staff carrying out the intervention.
Dementia special care units were randomly assigned to DCM or usual care. Nurses from the intervention care homes received DCM training and conducted the 4-months DCM-intervention twice during the study. The primary outcome was agitation, measured with the Cohen-Mansfield agitation inventory (CMAI). The secondary outcomes included residents' neuropsychiatric symptoms (NPSs) and quality of life, and staff stress and job satisfaction. The nursing staff made all measurements at baseline and two follow-ups at 4-month intervals. We used linear mixed-effect models to test treatment and time effects.
34 units from 11 care homes, including 434 residents and 382 nursing staff members, were randomly assigned. Ten nurses from the intervention units completed the basic and advanced DCM training. Intention-to-treat analysis showed no statistically significant effect on the CMAI (mean difference between groups 2·4, 95% CI -2·7 to 7·6; p = 0·34). More NPSs were reported in the intervention group than in usual care (p = 0·02). Intervention staff reported fewer negative and more positive emotional reactions during work (p = 0·02). There were no other significant effects.
Our pragmatic findings did not confirm the effect on the primary outcome of agitation in the explanatory study. Perhaps the variability of the extent of implementation of DCM may explain the lack of effect.
Dutch Trials Registry NTR2314.
Background
The main objective of care for people with dementia is the maintenance and promotion of quality of life (Qol). Most of the residents in nursing homes have challenging behaviors that strongly affect their Qol. Person-centered care (PCC) is an approach that aims to achieve the best possible Qol and to reduce challenging behaviors. Dementia Care Mapping (DCM) is a method of implementing PCC that has been used in Germany for several years. However, there are no data on the effectiveness of DCM or the challenges of implementation of DCM in German nursing homes.
Methods/design
In this quasi-experimental non-randomized cluster-controlled study, the effects of DCM will be compared to 2 comparison groups. 9 nursing homes will take part: 3 will implement DCM, 3 will implement a comparison intervention using an alternative Qol assessment, and 3 have already implemented DCM. The main effect outcomes are Qol, challenging behaviors, staff attitudes toward dementia, job satisfaction and burnout of caregivers. These outcomes will be measured on 3 data points. Different quantitative and qualitative data sources will be collected through the course of the study to investigate the degree of implementation as well as facilitators of and barriers to the implementation process.
Discussion
This study will provide new information about the effectiveness of DCM and the implementation process of DCM in German nursing homes. The study results will provide important information to guide the national discussion about the improvement of dementia-specific Qol, quality of care in nursing homes and allocation of resources. In addition, the study results will provide information for decision-making and implementation of complex psychosocial interventions such as DCM. The findings will also be important for the design of a subsequent randomized controlled trial (e.g. appropriateness of outcomes and measurements, inclusion criteria for participating nursing homes) and the development of a successful implementation strategy.
Trial registration
Current Controlled Trials ISRCTN43916381 .
Process evaluations are recommended to open the ‘black box’ of complex interventions evaluated in trials, but there is limited guidance to help researchers design process evaluations. Much current literature on process evaluations of complex interventions focuses on qualitative methods, with less attention paid to quantitative methods. This discrepancy led us to develop our own framework for designing process evaluations of cluster-randomised controlled trials.
We reviewed recent theoretical and methodological literature and selected published process evaluations; these publications identified a need for structure to help design process evaluations. We drew upon this literature to develop a framework through iterative exchanges, and tested this against published evaluations.
The developed framework presents a range of candidate approaches to understanding trial delivery, intervention implementation and the responses of targeted participants. We believe this framework will be useful to others designing process evaluations of complex intervention trials. We also propose key information that process evaluations could report to facilitate their identification and enhance their usefulness.
There is no single best way to design and carry out a process evaluation. Researchers will be faced with choices about what questions to focus on and which methods to use. The most appropriate design depends on the purpose of the process evaluation; the framework aims to help researchers make explicit their choices of research questions and methods.
Trial registration
Clinicaltrials.gov NCT01425502
The article describes an approach of systematic, rule guided qualitative text analysis, which tries to preserve some methodological strengths of quantitative content analysis and widen them to a concept of qualitative procedure. First the development of content analysis is delineated and the basic principles are explained (units of analysis, step models, working with categories, validity and reliability). Then the central procedures of qualitative content analysis, inductive development of categories and deductive application of categories, are worked out. The possibilities of computer programs in supporting those qualitative steps of analysis are shown and the possibilities and limits of the approach are discussed. URN: urn:nbn:de:0114-fqs0002204
The present study investigates the validity, reliability, and applicability of the German version of the QUALIDEM, which is used to measure the quality of life of people with dementia in nursing homes. The sample consists of data from 203 people (average age 84 ± 9 years, 74% female) with mild to moderate dementia and 283 persons (average age 86 ± 8 years, 79% female) with severe to very severe dementia. These are baseline data from two lighthouse projects on dementia (STI-D and InDemA). The investigation of the feasibility is based on four expert interviews. The construct validity of the 37-item version of the QUALIDEM shown by the factors satisfied behavior, unapproachable and unsatisfied behavior, positive self-image, negative affect, social relations, feeling at home, restless tense behavior, and having something to do were identified. Furthermore, for the 18-item version the following four factors were computed: satisfied behavior, unapproachable and unsatisfied behavior, restless tense behavior, and negative affect. Cronbach's α values for the determined factors are between 0.64 and 0.87 (37-item version) and between 0.61 and 0.83 (18-item version), which corresponds with a medium to high reliability (internal consistency). Furthermore, the student assistants assessed the QUALIDEM as applicable and practical.
Objectives: Survey results from 161 respondents trained in dementia care mapping (DCM) in the United States and United Kingdom (82 and 79 respondents, respectively) addressed the following: (a) To what extent are mappers using DCM? (b) How satisfied are mappers with DCM? (c) What affect does DCM have on mappers’ attitudes toward their dementia practice? and (d) What challenges are encountered by mappers in the use of DCM? Method: Analyses using odds ratios were used to make international and training-level (basic vs. advanced) comparisons. Results: Differences across countries were found in use of DCM and lack of satisfaction using DCM codes. Similarities were found with positive affects of DCM on attitudes and lack of time for DCM. Discussion: Differences in mappers’ experiences and perceptions exist across the two countries, warranting increased attention to the cultural contexts within which mappers are situated and how these affect the implementation of DCM within a country.
Evaluating complex interventions is complicated. The Medical Research Council's evaluation framework (2000) brought welcome clarity to the task. Now the council has updated its guidance
Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts.
We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts.
The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct.
The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.
Public health interventions tend to be complex, programmatic, and context dependent. The evidence for their effectiveness must be sufficiently comprehensive to encompass that complexity. This paper asks whether and to what extent evaluative research on public health interventions can be adequately appraised by applying well established criteria for judging the quality of evidence in clinical practice. It is adduced that these criteria are useful in evaluating some aspects of evidence. However, there are other important aspects of evidence on public health interventions that are not covered by the established criteria. The evaluation of evidence must distinguish between the fidelity of the evaluation process in detecting the success or failure of an intervention, and the success or failure of the intervention itself. Moreover, if an intervention is unsuccessful, the evidence should help to determine whether the intervention was inherently faulty (that is, failure of intervention concept or theory), or just badly delivered (failure of implementation). Furthermore, proper interpretation of the evidence depends upon the availability of descriptive information on the intervention and its context, so that the transferability of the evidence can be determined. Study design alone is an inadequate marker of evidence quality in public health intervention evaluation.
To help inform drug abuse prevention research in school settings about the issues surrounding implementation, we conducted a review of the fidelity of implementation research literature spanning a 25-year period. Fidelity has been measured in five ways: (1) adherence, (2) dose, (3) quality of program delivery, (4) participant responsiveness and (5) program differentiation. Definitions and measures of fidelity were found not to be consistent across studies, and new definitions are proposed. While there has been limited research on fidelity of implementation in the social sciences, research in drug abuse prevention provides evidence that poor implementation is likely to result in a loss of program effectiveness. Studies indicate that most teachers do not cover everything in a curriculum, they are likely to teach less over time and training alone is not sufficient to ensure fidelity of implementation. Key elements of high fidelity include teacher training, program characteristics, teacher characteristics and organizational characteristics. The review concludes with a discussion of the tension between fidelity and reinvention/adaptation, and ways of resolving this tension. Recommendations are made for developing a consistent methodology for measuring and analyzing fidelity of implementation. Further, researchers and providers should collaborate to develop ways of introducing flexibility into prevention programs.
The published literature on dementia care mapping (DCM) in improving quality of life and quality of care through practice development and research dates back to 1993. The purpose of this review of the research literature is to answer some key questions about the nature of the tool and its efficacy, to inform the ongoing revision of the tool, and to set an agenda for future research.
The DCM bibliographic database at the University of Bradford in the United Kingdom contains all publications known on DCM (http://www.bradford.ac.uk/acad/health/dcm). This formed the basis of the review. Texts that specifically examined the efficacy of DCM or in which DCM was used as a main measure in the evaluation or research were reviewed.
Thirty-four papers were categorized into five main types: (a) cross-sectional surveys, (b) evaluations of interventions, (c) practice development evaluations, (d) multimethod evaluations, and (e) papers investigating the psychometric properties of DCM.
These publications provide some evidence regarding the efficacy of DCM, issues of validity and reliability, and its use in practice and research. The need for further development and research in a number of key areas is highlighted.
Most randomised controlled trials focus on outcomes, not on the processes involved in implementing an intervention. Using an example from school based health promotion, this paper argues that including a process evaluation would improve the science of many randomised controlled trials.
Implementation fidelity refers to the degree to which an intervention or programme is delivered as intended. Only by understanding and measuring whether an intervention has been implemented with fidelity can researchers and practitioners gain a better understanding of how and why an intervention works, and the extent to which outcomes can be improved.
The authors undertook a critical review of existing conceptualisations of implementation fidelity and developed a new conceptual framework for understanding and measuring the process. The resulting theoretical framework requires testing by empirical research.
Implementation fidelity is an important source of variation affecting the credibility and utility of research. The conceptual framework presented here offers a means for measuring this variable and understanding its place in the process of intervention implementation.
Person-centered care (PCC) is a widely recognized concept in dementia research and care. Dementia Care Mapping (DCM) is a method for implementing PCC. Prior studies have yielded heterogeneous results regarding the effectiveness of DCM for people with dementia (PwD). We aimed to investigate the effectiveness of DCM with regard to quality of life (QoL) and challenging behavior in PwD in nursing homes (NHs).
Leben-QD II is an 18-month, three-armed, pragmatic quasi-experimental trial. The sample of PwD was divided into three groups with three living units per group: (A) DCM applied since 2009, (B) DCM newly introduced during the study, and (C) a control intervention based on a regular and standardized QoL rating. The primary outcome was QoL measured with the Quality of Life-Alzheimer's Disease (QoL-AD) proxy, and the secondary outcomes were QoL (measured with QUALIDEM) and challenging behavior (measured with the Neuropsychiatric Inventory Nursing Home version, NPI-NH).
There were no significant differences either between the DCM intervention groups and the control group or between the two DCM intervention groups regarding changes in the primary or secondary outcomes. At baseline, the estimated least square means of the QoL-AD proxy for groups A, B, and C were 32.54 (confidence interval, hereafter CI: 29.36-35.72), 33.62 (CI: 30.55-36.68), and 30.50 (CI: 27.47-33.52), respectively. The DCM groups A (31.32; CI: 28.15-34.48) and B (27.60; CI: 24.51-30.69) exhibited a reduction in QoL values, whereas group C exhibited an increase (32.54; CI: 29.44-35.64) after T2.
DCM exhibited no statistically significant effect in terms of QoL and challenging behavior of PwD in NHs. To increase the likelihood of a positive effect for PwD, it is necessary to ensure successful implementation of the intervention.
Public health interventions tend to be complex, programmatic, and context dependent. The evidence for their effectiveness must be sufficiently comprehensive to encompass that complexity. This paper asks whether and to what extent evaluative research on public health interventions can be adequately appraised by applying well established criteria for judging the quality of evidence in clinical practice. It is adduced that these criteria are useful in evaluating some aspects of evidence. However, there are other important aspects of evidence on public health interventions that are not covered by the established criteria. The evaluation of evidence must distinguish between the fidelity of the evaluation process in detecting the success or failure of an intervention, and the success or failure of the intervention itself. Moreover, if an intervention is unsuccessful, the evidence should help to determine whether the intervention was inherently faulty (that is, failure of intervention concept or theory), or just badly delivered (failure of implementation). Furthermore, proper interpretation of the evidence depends upon the availability of descriptive information on the intervention and its context, so that the transferability of the evidence can be determined. Study design alone is an inadequate marker of evidence quality in public health intervention evaluation.
In the light of recent research it is now possible to gain considerable insight into the subjective world of dementia. The uniqueness of each individual's experience, which is related to personality and defence processes, must always be taken into account. Six 'routes to understanding' are discussed, and the array of evidence is used to build up an overall picture of the domain. Comments are made on the psychological needs of people with dementia. Finally, a speculation is offered about the subjective consequences of those needs being met.
AimThe aim of this study was to investigate the role of leadership in the implementation of person-centred care (PCC) in nursing homes using Dementia Care Mapping (DCM). Background
Leadership is important for the implementation of nursing practice. However, the empirical knowledge of positive leadership in processes enhancing person-centred culture of care in nursing homes is limited. Method
The study has a qualitative descriptive design. The DCM method was used in three nursing homes. Eighteen staff members and seven leaders participated in focus-group interviews centring on the role of leadership in facilitating the development process. ResultsThe different roles of leadership in the three nursing homes, characterized as highly professional', market orientated' or traditional', seemed to influence to what extent the DCM process led to successful implementation of PCC. Conclusion and Implications for Nursing ManagementThis study provided useful information about the influence of leadership in the implementation of person-centred care in nursing homes. Leaders should be active role models, expound a clear vision and include and empower all staff in the professional development process.
The term person-centred care has become all-pervasive on the UK dementia care scene. It has been suggested that it has become synonymous with good quality care. It seems that any new approach in dementia care has to claim to be pc (person-centred) in order to be P.C. (politically correct). The term is used frequently in the aims and objectives for dementia care services and provision in the UK and the US, although what lies behind the rhetoric in terms of practice may be questionable.
Major difficulties arise when introducing evidence and clinical guidelines into routine daily practice. Data show that many patients do not receive appropriate care, or receive unnecessary or harmful care. Many approaches claim to offer solutions to this problem; which ones are as yet the most effective and efficient is unclear. We aim to provide an overview of present knowledge about initiatives to changing medical practice. Substantial evidence suggests that to change behaviour is possible, but this change generally requires comprehensive approaches at different levels (doctor, team practice, hospital, wider environment), tailored to specific settings and target groups. Plans for change should be based on characteristics of the evidence or guideline itself and barriers and facilitators to change. In general, evidence shows that none of the approaches for transferring evidence to practice is superior to all changes in all situations.
To provide a stronger evidence base for cultural change in the nursing home, this study elicited nursing, recreational therapy, and medical staff perceptions of barriers to the implementation of nonpharmacological interventions for the behavioral and psychological symptoms of dementia (BPSD).
Thirty-five staff members (registered nurses, licensed practical nurses, nurses' aides, recreational therapists, activity personnel, and medical directors) from six nursing homes located in Pennsylvania and North Carolina participated in the qualitative study.
A focus group methodology was used to capture discussions that were audio-recorded and transcribed verbatim. Data were analyzed using standard methods of content and thematic analysis.
Four broad themes were identified: the changing landscape; resident behaviors; reaching out to the person with dementia; and the educational needs of staff. The concept of time emerged as a key barrier to the use of nonpharmacological interventions for BPSD.
Successful use of nonpharmacological interventions requires the right staff with the right education at the right time. The Vulnerability Framework is a model that helped organize these findings into a meaningful perspective.
To effect change in the nursing home, the findings indicate a need for: implementation of staffing patterns that allow staff the time to make a difference in the care of residents with BPSD; development of educational programs that promote staff understanding versus control; and design of research studies that answer questions about the influence of time on the selection of interventions for BPSD.
Evidence for improved outcomes for people with dementia through provision of person-centred care and dementia-care mapping is largely observational. We aimed to do a large, randomised comparison of person-centred care, dementia-care mapping, and usual care.
In a cluster randomised controlled trial, urban residential sites were randomly assigned to person-centred care, dementia-care mapping, or usual care. Carers received training and support in either intervention or continued usual care. Treatment allocation was masked to assessors. The primary outcome was agitation measured with the Cohen-Mansfield agitation inventory (CMAI). Secondary outcomes included psychiatric symptoms including hallucinations, neuropsychological status, quality of life, falls, and cost of treatment. Outcome measures were assessed before and directly after 4 months of intervention, and at 4 months of follow-up. Hierarchical linear models were used to test treatment and time effects. Analysis was by intention to treat. This trial is registered with the Australia and New Zealand Clinical Trials Registry, number ACTRN12608000084381.
15 care sites with 289 residents were randomly assigned. Pairwise contrasts revealed that at follow-up, and relative to usual care, CMAI score was lower in sites providing mapping (mean difference 10.9, 95% CI 0.7-21.1; p=0.04) and person-centred care (13.6, 3.3-23.9; p=0.01). Compared with usual care, fewer falls were recorded in sites that used mapping (0.24, 0.08-0.40; p=0.02) but there were more falls with person-centred care (0.15, 0.02-0.28; p=0.03). There were no other significant effects.
Person-centred care and dementia-care mapping both seem to reduce agitation in people with dementia in residential care.
This paper describes DCM 8 and reports on the initial validation study of DCM 8.
Between 2001-2003, a series of international expert working groups were established to examine various aspects of DCM with the intention of revising and refining it. During 2004-2005 the revised tool (DCM 8) was piloted in seven service settings in the UK and validated against DCM 7th edition.
At a group score level, WIB scores and spread of Behavioural Category Codes were very similar, suggesting that group scores are comparable between DCM 7 and 8. Interviews with mappers and focus groups with staff teams suggested that DCM 8 was preferable to DCM 7th edition because of the clarification and simplification of codes; the addition of new codes relevant to person-centred care; and the replacement of Positive Events with a more structured recording of Personal Enhancers.
DCM 8 appears comparable with DCM 7th edition in terms of data produced and is well received by mappers and dementia care staff.
To validate the QUALIDEM, a quality of life measure for people with dementia within residential settings rated by professional caregivers.
In a sample of 202 residents of nursing homes Spearman rank correlations were calculated between the QUALIDEM subscales aand indices of convergent validity and discriminant validity, with dementia severity and need of care, with global QOL scores by the head nurse and family, and with self-report on COOP/WONCA Charts.
The one-method multi-trait matrix showed 90.5% of the correlations to be in support for convergent and discriminant validity. Low to moderate correlations were observed with dementia severity and need of care, confirming that QOL is not merely disease severity. Support for concurrent validity was found in correlations with QOL ratings by the head nurse. The QUALIDEM did not correlate with most of the family ratings or with the COOP/WONCA Charts.
The results of this validation study together with the obtained content validity through the method of construction provide sufficient support for validity of the QUALIDEM to be used for care evaluation and research in residential settings.
This paper presents the development and content of a person-centred nursing framework.
Person-centred is a widely used concept in nursing and health care generally, and a range of literature articulates key components of person-centred nursing. This evidence base highlights the links between this approach and previous work on therapeutic caring.
The framework was developed through an iterative process and involved a series of systematic steps to combine two existing conceptual frameworks derived from empirical studies. The process included the mapping of original conceptual frameworks against the person-centred nursing and caring literature, critical dialogue to develop a combined framework, and focus groups with practitioners and co-researchers in a larger person-centred nursing development and research project to test its face validity.
The person-centred nursing framework comprises four constructs -prerequisites, which focus on the attributes of the nurse; the care environment, which focuses on the context in which care is delivered; person-centred processes, which focus on delivering care through a range of activities; and expected outcomes, which are the results of effective person-centred nursing. The relationship between the constructs suggests that, to deliver person-centred outcomes, account must be taken of the prerequisites and the care environment that are necessary for providing effective care through the care processes.
The framework described here has been tested in a development and research project in an acute hospital setting. Whilst there is an increasing empirical base for person-centred nursing, as yet little research has been undertaken to determine its outcomes for patients and nurses. The framework developed can be described as a mid-range theory. Further testing of the framework through empirical research is required to establish its utility for nursing practice and research.
When caring for people with severe Alzheimer's disease (AD), the concept of the person being central is increasingly advocated in clinical practice and academia as an approach to deliver high-quality care. The aim of person-centred care, which emanates from phenomological perspectives on AD, is to acknowledge the personhood of people with AD in all aspects of their care. It generally includes the recognition that the personality of the person with AD is increasingly concealed rather than lost; personalisation of the person's care and their environment; offering shared decision-making; interpretation of behaviour from the viewpoint of the person; and prioritising the relationship as much as the care tasks. However, questions remain about how to provide, measure, and explore clinical outcomes of person-centred care. In this Review, we summarise the current knowledge about person-centred care for people with severe AD and highlight the areas in need of further research.
Dementia Care Mapping in nursing homes: a process analysis Effectiveness and costs of Dementia Care Mapping intervention in Dutch nursing homes
- G Van De Ven
- I Draskovic
- F Brouwer
- E Adang
- R Donders
- A Post
- S Zuidema
- R Koopmans
- M Vernooij-Dassen
van de Ven G, Draskovic I, Brouwer F, Adang E, Donders R, Post A, Zuidema S, Koopmans R &
Vernooij-Dassen M (2014) Dementia Care Mapping in nursing homes: a process analysis. In
Van de Ven G (Ed.), Effectiveness and costs of Dementia Care Mapping intervention in Dutch
nursing homes. Radboud Universiteit Nijmegen.
Dementia Care Mapping (DCM): initial validation of DCM 8 in UK field trials Use of Dementia Care Mapping for improved person-centred care in a care provider organisation -Guide
- Dj Brooker
- C Surr
Brooker DJ & Surr C (2006) Dementia Care Mapping (DCM): initial validation of DCM 8 in UK field
trials. International Journal of Geriatric Psychiatry 21(11), 1018-1025. doi: 10.1002/gps.1600
BSI-British Standards Institution (2010) PAS 800: 2010. Use of Dementia Care Mapping for improved
person-centred care in a care provider organisation -Guide. BSI-British Standards Institution,
London.
Dementia Care Mapping: Applications Across Cultures
- A Innes
Innes A (2003) Dementia Care Mapping: Applications Across Cultures. Health Professional Press,
Maryland.
Dementia Reconsidered: The person comes first
- T Kitwood
Kitwood T (1997a) Dementia Reconsidered: The person comes first. Open University Press, Berkshire,
UK.
Development of a framework for person-centred nursing Quality assurance criteria of the German medical advisory service of the statutory health insurance for institutional care
- B Mccormack
- Tv Mccance
McCormack B & McCance TV (2006) Development of a framework for person-centred nursing.
Journal of Advanced Nursing 56(5), 472-479. doi: 10.1111/j.1365-2648.2006.04042.x
Medizinischer Dienst des Spitzenverbandes Bund der Krankenkassen (2009) Quality assurance
criteria of the German medical advisory service of the statutory health insurance for
institutional care.
Using Dementia Care Mapping in Health and Social Care Settings
- L Heller
Heller L (2003) Using Dementia Care Mapping in Health and Social Care Settings. In Innes A (Ed.),
Dementia Care Mapping: Applications Across Cultures. Health Professional Press, Maryland.
Innes A (2003) Dementia Care Mapping: Applications Across Cultures. Health Professional Press,
Maryland.
Use of Dementia Care Mapping for improved person-centred care in a care provider organisation -Guide. BSI-British Standards Institution
BSI-British Standards Institution (2010) PAS 800: 2010. Use of Dementia Care Mapping for improved
person-centred care in a care provider organisation -Guide. BSI-British Standards Institution,
London.
Effectiveness and costs of Dementia Care Mapping intervention in Dutch nursing homes
- G Van De Ven
- I Draskovic
- F Brouwer
- E Adang
- R Donders
- A Post
- S Zuidema
- R Koopmans
- M Vernooij-Dassen
van de Ven G, Draskovic I, Brouwer F, Adang E, Donders R, Post A, Zuidema S, Koopmans R &
Vernooij-Dassen M (2014) Dementia Care Mapping in nursing homes: a process analysis. In
Van de Ven G (Ed.), Effectiveness and costs of Dementia Care Mapping intervention in Dutch
nursing homes. Radboud Universiteit Nijmegen.
Dienst des Spitzenverbandes Bund der Krankenkassen 2009 Quality Assurance Criteria of the German Medical Advisory Service of the Statutory Health Insurance for Institutional Care Essen
- Mds-Medizinischer
Quality assurance criteria of the German medical advisory service of the statutory health insurance for institutional care
Medizinischer Dienst des Spitzenverbandes Bund der Krankenkassen (2009) Quality assurance
criteria of the German medical advisory service of the statutory health insurance for
institutional care.