Critical Contextual Elements in Facilitating and Achieving Success with a Person-Centred Care Intervention to Support Antipsychotic Deprescribing for Older People in Long-Term Care

Abstract

Antipsychotic and other tranquilising medicines are prescribed to help care staff manages behaviour in one-quarter of older people living in Australian long-term care homes. While these medicines pose significant health risks, particularly for people with dementia, reliance on their use occurs when staff are not educated to respond to resident behaviour using nonpharmacological approaches. The Halting Antipsychotic use in Long-Term care (HALT) single-arm study was undertaken to address this issue with 139 people 60 years and over with behaviours of concern for staff living in 24 care homes. A train-the-trainer approach delivered person-centred care education and support for 22 HALT (nurse) champions and 135 direct care staff, dementia management education for visiting general practitioners (GP) and pharmacists, use of an individualised deprescribing protocol for residents, and awareness-raising for the resident's family. The HALT champions completed open-ended questionnaires and semistructured interviews to identify the contextual elements they considered most critical to facilitating, educating care staff, and achieving success with the study intervention. They reported that person-centred approaches helped care staff to respond proactively to resident behaviours in the absence of antipsychotic medicines; the champions considered that this required strong managerial support, champion empowerment to lead change, reeducation of care staff, and the cooperation of families and GPs.

Full text

Research Article
Critical Contextual Elements in Facilitating and
Achieving Success with a Person-Centred Care Intervention to
Support Antipsychotic Deprescribing for
Older People in Long-Term Care
Lynn Chenoweth ,1Tiffany Jessop,2Fleur Harrison,2Monica Cations,2
Janet Cook,1and Henry Brodaty1,2
1Centre for Healthy Brain Ageing, School of Psychiatry, UNSW Sydney, NSW 2052, Australia
2Dementia Centre for Research Collaboration, School of Psychiatry, UNSW, Sydney, NSW 2052, Australia
Correspondence should be addressed to Lynn Chenoweth; l.chenoweth@unsw.edu.au
Received 13 February 2018; Revised 19 April 2018; Accepted 13 May 2018; Published 8 July 2018
Academic Editor: H.-X. Wang
Copyright ©  Lynn Chenoweth et al. is is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Antipsychotic and other tranquilising medicines are prescribed to help care sta manages behaviour in one-quarter of older
people living in Australian long-term care homes. While these medicines pose signicant health risks, particularly for people with
dementia, reliance on their use occurs when sta are not educated to respond to resident behaviour using nonpharmacological
approaches. e Halting Antipsychotic use in Long-Term care (HALT) single-arm study was undertaken to address this issue with
 people  years and over with behaviours of concern for sta living in  care homes. A train-the-trainer approach delivered
person-centred care education and support for  HALT (nurse) champions and  direct care sta, dementia management
education for visiting general practitioners (GP) and pharmacists, use of an individualised deprescribing protocol for residents,
and awareness-raising for the resident’s family. e HALT champions completed open-ended questionnaires and semistructured
interviews to identify the contextual elements they considered most critical to facilitating, educating care sta,and achieving success
with the study intervention. ey reported that person-centred approaches helped care sta to respond proactively to resident
behaviours in the absence of antipsychotic medicines; the champions considered that this required strong managerial support,
champion empowerment to lead change, reeducation of care sta, and the cooperation of families and GPs.
1. Introduction
Dementiaisoneoftheleadingcausesofdisabilityinpeople
aged > years. Currently there is no approved treatment
available to prevent progression or cure dementia. It is
classied in the h edition of the Diagnostic and Statistical
Manual of Mental Disorders [] as a major neurocognitive
disorder, encompassing a range of degenerative conditions
characterised by decline in cognition, impairment in func-
tion, and frequently changes in the person’s behaviour [].
As dementia severity increases, certain behavioural responses
may change (e.g., aggression declines and apathy increases).
Someofthepsychologicalresponsesinpeoplewithdementia
include depression, psychosis, aggression, and wandering
from home []. Diminishing capacity and self-care ability,
coupled with increasing psychological responses/behaviours,
make it dicult for families to provide the level of care the
person requires [].
In these circumstances, people with dementia require
supported care services, including long-term care []. One of
the main reasons for the use of long-term care in Australians
with dementia is the presence of aggression, resistance to
care, and extreme agitation, for which antipsychotic and other
tranquilising medicines are prescribed in approximately %
of residents []. According to pharmaceutical guidelines,
antipsychotic medicines pose high risks for people with
Hindawi
BioMed Research International
Volume 2018, Article ID 7148515, 12 pages
https://doi.org/10.1155/2018/7148515

BioMed Research International
dementia and judicious prescribing and deprescribing are
recommended []. Antipsychotics have been associated with
more rapid cognitive decline [], increased risk for cere-
brovascular adverse events (CVAEs, e.g., stroke and transient
ischemic episodes), metabolic syndrome, delirium, and death
[, ]. In view of this adverse event evidence, and the
limited ecacy evidence [], deprescribing antipsychotics
is recommended for most people with dementia. When
deprescribing is not considered possible because of extreme
behaviour, lower doses of antipsychotics are advised along-
side nonpharmacological approaches [].
Oneofthemajorreasonsthatantipsychoticmedicines
continue to be used in long-term care is that the majority of
direct care sta have limited training in dementia care work,
and no qualications in nursing or allied health specialities.
ey oen lack the basic knowledge required for providing
quality dementia care and have limited skills in dementia-
specic communication and behavioural management [].
Without exposure to dementia-specic education, these
direct care sta are likely to attribute psychological causes
to dementia prevalence and the behaviours that they nd
concerning to a dementia diagnosis []. Consequently, while
this sta is charged with providing care and support for
people with dementia, oen with very limited supervision
fromaqualiednurse,theymaynditdicultandburden-
some to manage coexisting physical, behavioural, and mental
health issues []. Direct care sta may, therefore, struggle
to communicate and engage the person with dementia in
meaningful conversation and leisure activities and may not
know how to prevent and deal with resistance during a care
event [].
As well, without dementia-specic knowledge direct
care sta have less hopeful attitudes towards people with
dementia, do not anticipate meaningful responses from them,
and have low expectations of improvements in the person’s
functional and cognitive ability []. In these circumstances,
sta may disengage from the person psychologically and
socially and can inadvertently reinforce the behaviour they
nd challenging by reacting negatively to the person and/or
the behaviour [, ]. Sta may also fail to support the
person’s positive, prosocial behaviour when they are verbally
andphysicallyagitated[].Targetededucationcanhelpto
address negative sta behaviour by clarifying misconceptions
about cognitive impairment in dementia, give advice on the
dierent reasons and remedies for the person’s behaviour, and
increase sta’s condence and skills in providing individu-
alised care [].
Dementia education based on a person-centred care
framework [] helps long-term care sta to recognise that
many of the person’s behaviours, such as agitation and
resistance to care, arise from the person’s interactions within
the care context. rough exposure to this educational
focus, sta come to understand that people with dementia,
like themselves, exist in a social, relational context, and
that when sta make genuine attempts to develop positive
and enriching interpersonal relationships with people with
dementia, they can help to reduce the disabling eects of
dementia and promote well-being []. A person-centred
approach to dementia care places considerable value on
understanding the person’s unique identity and personality,
helping the person to feel a sense of self-worth and value
through tailoring services to the individual’s psychosocial
needs, providing options for continued social engagement
and access to meaningful life activities, and including the
person in decisions about their care and daily life experiences
as much as possible. is approach to dementia care is
eective in improving the quality of care, such as bathing
and social and recreation activities [, ], improving well-
being [], reducing various forms of agitation [, ], and
reducing the need for antipsychotic medicines to manage
behaviour [].
Forperson-centredcaretobecomeapracticalrealityin
reducing, or eliminating, the use of psychotropic medicines
in people with dementia, its application must be interpreted
in the context of the person and their personal characteristics,
collegiate relationships, and the healthcare organisational
circumstances []. e model is best implemented when the
entire system is framed by policies to guide implementation
across the organisation, as well as within supportive medical
and ancillary services []. Leadership at senior and middle
management level is a key factor in eective, system-wide
adoption of the person-centred approach [, ], including
willingness to introduce targeted education, training and
supervision for all direct care, and support and ancillary sta
[]. Despite the evidence for a person-centred approach,
many long-term residents with behavioural issues are still
prescribed antipsychotic medicines [].
In response to the continued reliance on antipsychotic
medicines for people with behaviours that cause diculties
for long-term care sta, we conducted the Halting Antipsy-
chotic use in Long-term care (HALT) study []. e study
implemented a multifaceted intervention, using a train-the-
trainer approach to deliver person-centred dementia care
education and support for HALT (nurse) champions and
direct care sta, dementia management education for visit-
ing general practitioners (GP) and pharmacists, awareness-
raising for the resident’s family and use of an individualised
deprescribing protocol for participating residents which fol-
lowed Australian guidelines stipulating a dose reduction of
%everyweeksandceasingaerweeksonthemin-
imum dose, withdrawing one antipsychotic at a time, with
risperidone (if prescribed) to be withdrawn last []. Some of
the participating GPs prematurely applied the deprescribing
protocol for  of the residents. e GPs’ adherence to the
deprescribing protocol is the subject of a HALT substudy,
with a manuscript in process. While  (.%) of the
participating residents were initially deprescribed, there was
a cessation or a reduction in dose of antipsychotic use in four
out of ve of  residents remaining at -months follow-
up, without an increase in substitute medicines. e number
of participants on regular antipsychotics over -months
reduced by .% (% CI: .–.) [].
is HALT substudy aimed to identify the champions’
experiences with applying the person-centred care training
when providing leadership to direct care sta in person-
centred dementia care. In this article we focus on the
champions’ use and satisfaction with the training program
resources and recommended techniques, their perceptions

BioMed Research International 
of the enablers and barriers to person-centred approaches
in practice and whether the person-centred care approach
helped to reduce resident behaviours, and their reections
on how the person-centred care approach adopted had an
inuence on the culture of dementia care.
2. Materials and Methods
e HALT study, including this substudy, was approved by
the university’s research ethics committee (HC) and was
registeredwiththeAustralianNewZealandClinicalTrials
Registry (), with study methods and results
reported according to the COREQ guidelines.
2.1. Setting and Participants. HALT was conducted as a
single-arm longitudinal study in a convenience sample of
 long-term care homes ( private,  charitable, and 
community-based, each with > beds) in the greater Sydney
region,Australia.Informedproxyconsentwasobtainedfor
all but one of the study participants; one resident was able
to provide her own consent. Appointed nurses from each
of the homes recruited  people aged  or older, who
livedinthehomefor≥ month and were taking regular
antipsychotic medicines for ≥ months, of whom  were
eligible. Eligibility was assessed via sta interviews and
le audits. Residents were excluded if terminal illness or
a primary psychotic condition was present, or if they had
extreme behaviour that might be too dicult to manage
in the long-term care setting (score ≥ on the nursing
home version of the Neuropsychiatric Inventory (NPI-NH)
[], domain scores of  for at least two of delusions,
hallucinations, agitation/aggression, anxiety or disinhibition,
and occupational disruptiveness score ≥ for at least two of
these domains). e extreme behaviour exclusion criterion
was informed by contemporaneous Australian Department
of Health rules for severe behaviour supplement [].
e  HALT champions recruited to the study were
volunteer registered nurses from each of the participating
homes who were identied by their managers as having
leadership qualities in educating/training and supervising
direct care sta in person-centred care techniques for par-
ticipating residents. e study’s project coordinator recruited
and consented one or two experienced senior nurses within
each of the  participating care homes to take on the
champion role.
2.2. Study Intervention: Person-Centred Education/Training
and Support. e person-centred education/training and
support component of the multifaceted study intervention
used an evidence-based train-the-trainer approach to deliver
person-centred dementia care education and support [16,
19] for HALT (nurse) champions and direct care sta.
Once consented the champions attended a -day workshop
delivered in groups of - by the study dementia nurse
specialist. Champions were provided with a training manual
and set of dementia resources which outlined practical
strategies for problem-solving issues with individual resident
behaviours. e main learning objectives of the champion
education/training course included educating direct care sta
to value and respect the resident in all interactions; regard
the resident as a complete individual; seek to understand the
experiences and behaviour of the resident from their per-
spective; understand that all resident behaviour is a form of
communication; and make every attempt to create a positive
care and social environment to prevent the development of
agitated behaviour.
Experiential and adult learning techniques were used in
the training program, including role play of person-centred
approaches with champion-identied examples of known
residents with behaviour that was concerning for direct care
sta; trainer demonstration of how these behaviours might be
investigated and approached during role play; group activities
which encouraged expression of feelings through sharing
observations, and engaging with emotions by entering into
the reality of the person with dementia and not simply
trying to distract them; and facilitating shared learning by
assisting the champions to use the dierent learning resources
and techniques in preparation for their role, such as care
planning with reference to residents recruited to the study,
and use of practice memos and mini-tutorials on person-
centred approaches that they planned to use during sta
handovers.
Along with a range of strategies to facilitate person-
centred care practice with direct care sta, the champi-
ons were provided with helpful resources such as person-
centred care plans which focused on maintaining resident
function, engagement, and well-being; care management
and behaviour prevention/reduction techniques and pro-
tocols; case management and team leadership techniques;
the VIPS[] model of person-centred care; relationship-
building processes; and transition and continuity planning.
e study’s emergency behaviour response protocol (Sup-
plemental File (available here)) included these key person-
centred approaches when investigating, interpreting, and
responding to resident behaviour that sta found extremely
challenging.
Champion education and supervision of  direct care
sta occurred in consultation with their managers, the
project coordinator, and the dementia nurse specialist, which
continued on a regular basis until follow-up. e dementia
nurse specialist and the project manager provided on-site
and phone support to the champions as they commenced
educating and supervising direct care sta in person-centred
care and behaviour management.
2.3. Measurement and Data Collection. e HALT sub-
study identied the contextual elements that the cham-
pions considered most critical in facilitating, adhering to
andachievingsuccesswiththeperson-centredcarecom-
ponent of the HALT intervention, and how this change
process impacted on care delivery and outcomes for par-
ticipating residents from the champions’ perspectives. To
obtain these data a questionnaire was completed by HALT
champions before and aer they participated in the educa-
tion/training program, and they were interviewed at study
follow-up.

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e pre/post education/training questionnaire was based
on process evaluation principles and included eight opened-
ended questions on the champion’s learning needs, expec-
tations, and achievements, including their knowledge of
dementia and dementia care, application of dementia care
skills/strategies, and knowledge and application of person-
centred responses to behaviour in dementia. One additional
item was included in the posteducation course questionnaire
whichaskedtheparticipantstoratetheprogramqualityon
a Likert scale ranging from  ‘did not meet learning needs’ to
 ‘met all learning needs’. Questionnaires were administered
by the research assistants immediately prior to and at the
conclusion of the champion’s education/training course, and
participant responses were handwritten. Completed ques-
tionnaires were returned to the study research assistants in
sealed envelopes for data entry and analyses.
One-on-one champion interviews were informed by the
substudyaims.einterviewswereconductedbytheproject
coordinator in private rooms within the aged care home,
using a semistructured interview guide. For a small number
of champions who were unable to be interviewed during
working hours, one-on-one interviews were conducted by
telephone. Interview questions included a mix of closed and
open-ended items, and items which asked participants to
give ratings to xed questions using Likert scale responses,
such as ‘none’, ‘a little’, ‘some’, ‘a lot’ and ‘substantial’ and
‘very low’, ‘low’, ‘neutral’, ‘high’, and ‘very high’. e  topics
covered included work-related demographics; progress and
details on instituting person-centred approaches in care for
included residents; barriers and enablers with instituting
the person-centred approach; strategies used successfully in
reducing triggers and resident behaviours; impact of person-
centred approaches on resident behaviour; impact of on-site
person-centred education, training, and supervision on care
practices; and factors involved in instituting a person-centred
workplace culture. Champion responses were tape recorded
and key statements were hand-recorded on the survey and
interview forms. Handwritten statements were checked for
accuracy with participants at the end of the survey. Since
the tape recordings were transcribed verbatim, they were not
returned to participants for their review.
2.4. Data Analyses. Questionnaire responses, interview tran-
scripts, and notes recorded by the data collector were sorted
and classied with computer soware, NVivo [], and
were content analysed by experienced qualitative researchers.
ree study team members with expertise in this form of
data analysis independently employed an iterative process to
code these data and identied the core concepts, deriving
key themes from the data as a whole. ematic analysis was
guided by the aprioritopic areas of the champion ques-
tionnaire and semistructured interview questions. Emphasis
was placed on subjective experiences and the meanings that
the champions attached to that experience []. Key themes
were independently analysed by two of study team members
for champion questionnaire and interview responses and
then conrmed and/or corrected by the third team member
[]. Consensus was reached between the three study team
members regarding the categories and themes for each of
the key domains of interest. is approach to data analysis
produced an in-depth interpretation of the dynamic and
subtle interplay of factors occurring at the individual, group,
and organisational level in regard to the implementation
of the study intervention, its potential generalisability, and
optimisation in routine long-term care practice [].
3. Results and Discussion
3.1. Results. e substudy results are presented according to
the questions which guided the champion questionnaires and
interviews, concluding with the themes derived from these
data.
3.1.1. Work-Related Demographics. e  champions were
all female registered nurses, with a range of educational
qualications and working at dierent levels of authority.
Educational preparation included hospital-training certi-
cate and/or diploma and/or a bachelor and/or a master
degree in a health discipline. Champion work roles included
senior registered nurse (n=), clinical nurse specialist (n=),
clinical nurse consultant (n=), nurse practitioner (n=),
quality manager (n=), deputy director of nursing (n=),
and care unit manager (n=). Most of the champions had
participated previously in some form of dementia-specic
education within the care home or externally, ranging from
certicate to degree-level courses.
3.1.2. Achievement of Learning Objectives. All  champions
responded that the education/training course had met many
of their learning objectives, particularly on how to use a
person-centred care approach to reduce the incidence and
severity of resident behaviour, techniques in communicating
with residents with dementia and behavioural issues, and
how to change sta ’s reliance on antipsychotic medicines
for resident behaviours they found dicult to manage. ey
considered the course had taught them strategies which
they intended to utilise in practice as a way of facilitating
implementation of person-centred care. e following state-
ment of one champion’s satisfaction with the education and
support received was similar to sentiments expressed by most
Champions:
“Sta have received excellent education and feel condent
andinvolvedintheproject.eyhavefoundthattheprocess
has been very consultative” (SC).
e most useful strategies included how to interpret
a need from behaviour, procedures for managing complex
change, showing direct care sta how to be therapeutic agents,
how to use practice improvement memos, microtraining and
person-centred care planning, and how to use the VIPS []
model in emulating the person-centred care approach in
practice. e postcourse questionnaire responses indicated
that champions considered there was a need to know more
about psychotropic medicines and how to manage resident
aggression, especially in care delivery. A common response
was the need for dementia specialists or educators to be
available for onsite follow-up support or training for direct

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caresta.Onascaleof‘didnotmeetlearningneeds’to
‘met all learning needs’,  champions gave a rating of ‘’ and
 gave a rating of ‘’.
3.1.3. Progress with Instituting Person-Centred Approaches
in Care. All  champions were positive about the HALT
program before and aer its introduction, and this sentiment
continued at follow-up. As one of the champion’s reected:
“I think the project has created awareness that anti- psy-
chotic medications are dangerous and not always the answer.
Ithasallowedstatowitnessrst-handthebehavioursof
residents who have been successfully de-prescribed. It has
shownthatitisamyththatbehavioursautomaticallyincrease
when antipsychotic medications are decreased” (MC)
e champions reported that once they introduced the
strategies they learned through the education/training course
within the care home, the majority of the direct care sta
were enthusiastic about the person-centred care approach
andwerewillingtoapplytheseapproachesforbehaviour
that was troubling for the resident and themselves. Direct
care sta were also curious to see whether person-centred
approaches to behaviour prevention and management were
useful. Most of t he champions found that direct care sta were
willing “...to give it a try and see how it goes” (VC).
It was universally agreed that the managers provided
good support for the champions and enabled them to
undertake the level of education, training, and support they
needed to pass on the learning obtained during the educa-
tion/training course. Time was set aside for champions to
work directly with sta. Shared governance with champions
was a feature of the managerial leadership for the project,
evidenced by the initiatives taken by champions to educate
sta in person-centred approaches to care, and in the learning
strategies they used for person-centred responses to resident
behaviour. However,  out of  champions advised that they
undertook a high level of unpaid out-of-hours work to initiate
and continue the education, training support for sta. In a
few cases the managers rostered champions o-duty, but paid
them, to provide sta education/ training and support.
For the most part champions were fully involved in imple-
menting the onsite education/training using many of the
learning resources provided, including person-centred care
and lifestyle plans, mini-tutorial and case conference pro-
tocols, practice memos, role play guidelines, and behaviour
response ow charts. ey took a range of opportunities to
educate, train, and support sta colleagues, including during
shi handover times, in targeted education sessions with care
sta, in regular debrieng sessions to review progress with
targeted sta, and conducted case study reviews with the
whole team, case conferences with the family, nurses and
allied health sta, and supervision of sta in daily practice.
ese sessions ranged from “daily mini learning tutorials
at shi handovers”(MRC),“20 to 30-minute education
sessions with direct care sta up to four times each week”
(SBC) and “education sessions of one or more hours once
each week” (SLC), and some champions “gave advice during
case conferences on specic non-pharmacological techniques
suitable for individual residents” (BHC).
e champions attempted to educate, train, and support
as many sta as possible, estimating that they reached
approximately -% of all sta, including sta working on
weekends in some of the homes. Education techniques were
based on the HALT person-centred care training program
folder and resources, supplemented by education provided
by external consultants and via DVDs and other online
resources provided by dementia support and training ser-
vices. All  champions considered that sta’s level of knowl-
edge and awareness of nonpharmacological management of
resident behaviour improved with the education, training,
and support they received through the HALT intervention.
ey recounted dierent ways that the techniques taught in
thecoursehelpedthemtounderstandandworkonminimis-
ing triggers which individual residents found distressing. One
of the champions explained this process:
“Wecheckedthereasonsforagitation,suchasconstipa-
tion, pain and thirst, and attended to any issues that seemed
to be a trigger. We also asked the doctor to attend to issues
quickly, such as pain” (SLC).
While the support from the study dementia nurse spe-
cialist and project coordinator was appreciated by champions,
it was generally thought that more onsite and on-going
education was needed for all sta. Two of the champions
requested that “HALT sta explain the concepts to all sta,
on all shis” (BPC), “as some sta need to have simplied a
version of how conform with the care protocol” (SC). Where
the champions were not involved from the beginning of the
project, such as when new champions were enrolled following
the resignation or transfer of a former champion and/or care
unit manager, there was a higher need for onsite education
and support by the study team members. As direct care sta
turnovercontinuedtobeanissueinsomeofthehomes,
the champions found it dicult to ensure all new sta were
exposed to the same level of education and support in person-
centred approaches to care as occurred with more stable
sta. It was acknowledged that “continued, on-site education
and training in nonpharmacological management of resident
behaviour” (BHC), with the support of managers, was
essential to continue deprescribing of psychotropic medicines
for current and future residents with dementia.
Anissueraisedbysixofthechampionswastheneed
for additional onsite education of person-centred approaches
for direct care sta from culturally and linguistically diverse
backgrounds (CALD), where more discussion and experi-
ential education for understanding these concepts and their
practical application were required. Where a facility had
a high proportion of CALD families and residents, it was
suggested that translators and written translations would
assist in the implementation and acceptance of the person-
centred approach. is issue was explained by one of the
champions:
“esestaneedtorstofallbehelpedtounderstandthe
concept of helping residents to make decisions for themselves
and to express their own personality, then feel condent to
try dierent approaches to meet the resident’s needs, because
all residents are dierent, and they have dierent issues and
respond dierently to triggers that support their well-being
and also ill-being. If the information about the care model

BioMed Research International
couldbetranslatedfortheoverseas-bornstathatwould
help” (BPC).
3.1.4. Enablers and Barriers in Adhering to the Person-Centred
Approach to Care. e context of the care environment
provedtohavethegreatestimpactontheoperationalisa-
tion of person-centred care practices. Champions reported
that their work cultures were developed to value, respect,
empower,andgivechoiceforthechampions,thesta,and
the residents. e organisational climate and culture created
by the managers supported the committed vision of a person-
centred approach to behaviour reduction and management
andalsoinuencedtheactionsandinteractionsofthesta
providing the care. e champions spoke of how direct care
sta were encouraged and assisted to put their relationship
with the person before the tasks they needed to undertake.
is was greatly helped by champions working with sta to
plan care and behaviour management in ways that focused
ontheperson’suniquepreferencesandneeds.eperceived
enablers and barriers to making these practice changes are
listed in Table .
3.1.5. Sta Progress in Using Person-Centred Responses to
Resident Behaviours. e  champions considered that the
majority of direct care sta derived deep satisfaction and
meaning from their work and the relationships that they
formed with the residents, particularly aer learning how
dementia aects the resident’s communication and other
abilities. ey advised that most of the direct care sta worked
together to provide a sensitive way of understanding and
responding to each resident’s needs and unique personality.
Championsidentiedthatthisapproachhelpedtopro-
vide culturally appropriate solutions in regard to behaviour
management, “because it was based on the unique priorities
and perceptions of the person, their family and their cultural
context” (SLC).
An important change for direct care sta was the incen-
tive for them to minimise, and challenge systems-driven
services that were not in the best interests of the resident.
is was enabled by managerial and champion leadership
in shiing in the organisation’s control over care schedules,
and their role in negotiating schedules and care/treatment
priorities with families and GPs. is leadership created a
climatethroughoutthecarehomeandallowedthemajority
of champions sucient time and resources to lead the change
process.
e champions reported seeing improvements in the
quality of care for residents with facilitated learning in prac-
tice. Words used to describe these improvements included
sta ‘being more responsive’ (SLC), “more respectful”
(SBC), “giving care in a timely way”(VC),and‘being more
condent in responding to dicult behaviours”(BHCO).
Knowledge and skill transfer were reported to occur across
the sta group as a whole, with emphasis placed on discussing
behavioural issues and management for dierent residents at
sta meetings, case conferences, and shi handovers. Sta
became more proactive in requesting that residents’ GPs
deprescribe antipsychotics and prescribe regular analgesia
where the sta identied this as a potential, or actual, cause
of agitation and resistance in care. e most commonly stated
improvements arising from the education and training were
sta ’s recognition and removal of behaviour triggers relevant
to the individual resident, and the sta’s identication and
responses to the residents’ unique needs.
Itwasnotedbynineofthechampions,however,thatsome
direct care “sta needed much more education and training, as
well as role modelling and practice supervision, than others”
(WC01),since“iftheresidentisnotsettled,nomatterwhatyou
try, the sta do not know where to go with this” (BHC). For
these sta the most successful learning came through wit-
nessing successful responses to resident behaviours by their
colleagues and the champion, and by having opportunities
to practice these techniques through role modelling. Once
successes in reducing distressing behaviours were observed
and/or experienced by direct care sta and then discussed
among the team, these sta gained more condence to initiate
new approaches to care.
3.1.6. Strategies Used Successfully to Reduce Triggers for Res-
ident Behaviours. e major strategies that all champions
found useful when helping direct care sta to become
aware of potential triggers for individual residents included
searching out information on the resident’s previous lifestyle
and history from family and client records, discussing the
resident’s unique needs with nursing care and allied health
teams in dedicated meetings and at case conferences, and
spending more time with the resident to learn about their
preferences in care. As one champion noted:
“... taking small, well-planned steps (towards change)
helps to convince the sta of how important it is to take notice
of what the resident is trying to tell us” (SBC).
Another champion identied that
“.... helping one resident (to be less agitated), helps other
resident to feel settled” (VC).
A frequent example given of the type of change made by
direct care sta included paying attention to the potential for
residents to experience pain, which resulted in “better pain
assessment and an increase in needed analgesia” (BHC).
It was considered by all  champions that regular pain
relief greatly reduced resident distress, even when aggressive
andagitatedbehaviourwassevere.Otherpain/discomfort-
relieving methods were also reported, such as having “the
physiotherapist ensure that the resident had correctly tting
shoesandwasinvolvedinamorefrequentexerciseprogram”
(MRC).
A further strategy reported by  of the champions in
reducing behaviour triggers was allocating time for direct
care to communicate with residents when verbal agitation
was present, and where this appeared to be “associated
with loneliness and boredom” (BLC). As well,  of 
champions reported that they facilitated one-on-one com-
munication responses and individualised care for residents
during periods of extreme agitation and other forms of
distress. ese changed approaches to behaviour reduction
and management helped direct care sta to realise that res-
identbehaviourwasoenassociatedwithanunmetphysical

BioMed Research International 
T : Enablers and barriers to implementing person-centred care approaches.
Enablers for the person-centred care approach
Enablers Examples provided by Champions
Management support for
incorporating personalized
care into daily care
practices
“...allowing residents to sleep-in and providing them with breakfast
when they awoke and requested it”(SCC)
Management allowing
Champions and sta to try
out new ideas
“.... letting the nurses try dierent approaches for some residents....and
discovering what worked, and what was not working”(SLC)
Shared governance in
decision-making
“...input and feedback and discussion with direct care sta on resident
preferences, needs and issues”
(WMC)
Clear communication
between managers, nurses,
direct care sta, the
Champions, the resident’s
family and the GPs
‘...good communication greatly improved the buy-in by all
stakeholders and the capacity for speedy problem solving on issues
regarding resident health and well-being”(AHC)
Barriers to the person-centred care approach
Barriers Examples provided by Champions
Reluctance of residents’
families to agree to
deprescribing
“....it was important for Champions to give families and GPs advice on
the person-centred approach to behaviour reduction and management,
to show how this approach was embedded in the approved deprescribing
protocol and to emphasise that the approach was unlikely to cause any
harm to the resident” (MC)
Reluctance of resident’s GP
to deprescribe
“...the GPs needed to feel they were making the decision based on
knowledge and evidence”(BHC)
Reluctance of some nurses
to support deprescribing
“some RNS would only agree to comply if the doctors allowed it”
(BPC)
“somedirectcarestaexpressedfeartoRNs(nurses)thattheycould
suer assault from a physically stronger and aggressive resident”(SC)
Negative family attitudes
towards
non-pharmacological
management of behaviour
“a culture of blame seemed prevalent if sta were unable to contain the
resident’s behaviour,”(WDC)
Task-focused care culture “.... not having the person-centred approach in the forefront of their
thinking amid all the things they have to do for residents”(BLC)
Time to implement
person-centred behaviour
responses
‘...(direct care sta) being too busy to really take notice of what was
going on for residents”(WC)
Lag time in reporting of the
study ndings
“....(Champions) having insucient feedback on the study’s progress”
(MRCO), “...(study ndings) would have helped to inspire the direct
care sta to maintain their interest and commitment to person-centred
approaches to behaviour reduction and management”(BHC)
and/or psychosocial need. Direct care sta were, therefore,
“more interested to discuss and collaborate on solutions to
reduce triggers for resident behaviours”(WC).
3.1.7. Perceived Impact of the Person-Centred Approach on Res-
ident Behaviour. Since all  champions facilitated person-
centred care with direct care sta, they recounted numerous
examples of their observed changes to care practices and
the impact these changes had on participating residents. All
champions considered that the person-centred approach was
helpful for the majority of residents, not just those enrolled
inthestudy.Reportedimprovementsinoutcomesfor
participating residents were described in terms of functional
status, overall well-being, and behaviour reduction. Improve-
ments reported included the residents being calmer, more
cooperative, more social, more independent in activities of
living, and less anxious. e champions reported that these
positive changes tended to occur gradually at rst, but “once
the sta became aware of how their care and therapy practices
had an inuence on the resident’s function and well-being,
stamadegreatereortstoidentifyandmeetindividual
resident needs” (SLC). With regard to observed improve-
ments in resident function and well-being, the champions
noted that individual residents increased their involvement in

BioMed Research International
communicating and engaging with others in pleasurable
activities, their appetite and sleep time and quality improved,
and the incidence and severity of agitation reduced, such
as “repetitive calling out” (OCC), “screaming” (BPC),
and “resistance to personal care” (RSKC). Some champions
observed that the residents who were responsive to person-
centred care approaches were “morealert,wereableto
mobilise more frequently and had less falls” (SBC).
Nevertheless, some resident behaviours and activities of
living were not observed to improve with deprescribing.
Two of the champions noted that these residents were
“mostly women with nonaggressive behaviour”(VC)and
“with no prior mental illness” (SLC).Where residents had
mild-moderate behavioural issues prior to deprescribing, the
champions observed minimal change in these behaviours.
Two of the champions advised that where deprescribing
produced no changes in resident function, well-being and
agitation, this may have been related to the resident selection,
i.e., “residents with less troubling behaviours”(WC).It
was noted, however, that minimal reductions in behaviour
incidence and severity was likely a positive outcome for
these residents, given the proven iatrogenic adverse eects of
psychotropics in dementia []. As previously identied, two
of the champions reported that a small number of residents
had a return of previous behaviours associated with long-
standing mental illness
3.1.8. Factors Involved in Instituting a Person-Centred Work-
place Culture. Champions recounted many examples of how
their care home managers, champions, and direct care sta
developed a coordinated system of sharing the common
values of person-centred dementia care, while understanding
the value that their unique roles played in caring for residents.
Improved communication systems between  of the 
champions, managers, and direct care sta also helped to
share knowledge about residents, in order to develop greater
awareness of what precipitated and helped to reduce agitation
and other behaviours in residents. e champions recalled
how positive interactions between direct care and therapy
sta, and managers, were key to supporting the personhood
of individual residents; this occurred mainly by developing
empathetic working relationships.
e other important approach to developing a person-
centred culture occurred through the champions working
hard to establish care partnerships, through enabling direct
care sta, residents, and families to have direct involvement in
decision-making in care schedules and treatment regimens.
Champions spoke of how partnerships were formed with
families through sta developing an understanding that each
resident had a unique history and that residents and/or
families were entitled to indicate their preferences in daily
living activities and the way that care was provided. As one
champion found:
“Helping the family to get involved in discussing their
relative’s issues and needs, and what might be causing their
distress, this will help the sta to feel more connected and
morewillingtoworkwiththefamilytosortouttheseissues.”
(AHC).
By taking this approach, direct care sta learned how to
humanise care practices, how to help residents maintain their
personhood, dignity, and decision-making; and how to indi-
vidualisecareandtherapyactivitiesthatwerepreferredbythe
resident and/or their family, because “each person is dierent
and has dierent issues, so dierent approaches are needed to
help them” (BHC). Sta learned to recognise the centrality
of creating an environment for positive relationship-building
between themselves, the resident, the families, and each other
in assisting the resident to be less stressed in day to day living.
Champion recommendations for further development
of a person-centred workplace culture included: “education
and training for all sta in person-centred care approaches,
as well as in how to recognise and reduce behaviour trig-
gers” (OOC); “establishing mechanisms in care sched-
ules/regimens to allow direct care sta to get to know their
residents’ backgrounds, personalities, preferences and needs”
(WC); “welcoming and encouraging family involvement
in discussions of residents needs and preferences”(BLC);
“providing meaningful daily living activities in ways that create
well-being for the resident” (WHC); “personalizing the care
environment in ways that help the resident to feel safe and
calm” (RKC); “enabling direct care sta to oer exible care
routines without repercussions from other departments such as
catering” (BPC); and “providing managerial leadership for
sta continuity and exibility in care delivery” (WMC).
4. Discussion
is substudy of the HALT trial provided data on the cham-
pion’s experiences of how person-centred training program
helped them to provide the groundwork for a change in
dementia care, their observations of the impact it had on
resident behaviour, and their perceptions of its inuence on
dementia care culture in relation to the underlying mech-
anisms of the care context, management systems, stang
arrangements, and resident issues. While this substudy does
not report on the answers to these questions from the
perspective of the study’s GPs, families, direct care sta,
and care managers, the champions’ insights provide valuable
guidance on how sta leaders can progress needed change,
andinidentifyingwhatstructuralfactorsplaytheirpartin
successful implementation of person-centred care. e main
themes arising from these data focus on organisational and
sta readiness to accept, believe in and embrace practice
change, by instituting a planned change management proce-
dure, empowering champions to drive the change process,
and empowering direct care sta to adopt the change in
care practices. e champion interview ndings indicate
that success with implementation related to four key fac-
tors: behaviour management improvement was considered
a priority for champions and managers; leadership was
in place to support person-centred care across the care
unit; a ‘bottom-up’ change model worked alongside ‘top-
down’ change approach; and the person-centred approach to
behavioural issues was appropriate to the context.
ese ndings contribute to the literature by explain-
ing the discrepancies between the expected and observed

BioMed Research International 
outcomes for some residents, help in understanding how the
care context inuenced outcomes, and provide insights to aid
future implementation of person-centred care for residents
with behaviours that are concerning for direct care sta [].
e champions also provided many useful suggestions on the
potential generalisability of the change processes employed
and optimisation of person-centred care in routine long-
term care practice, similar to recommendations arising from
previous person-centred care research [, ].
e positive outcomes reported by the champions were
dependent on their acquisition of detailed knowledge, skills,
condence, and competencies for leading the change process.
It appears that many of the dierent resources and strategies
gained through the training course, such as practice memos,
mini-tutorials, person-centred care plans, and the VIPS []
approach to implementing person-centred care, were helpful
in applying knowledge into practice. As identied in a
previous person-centred care study, the onsite and telephone
follow-up support provided by the project coordinator and
the dementia nurse specialist helped the champions to con-
solidate their learning and to improve their condence in
facilitating learning in practice [].
Nevertheless,asfourofthechampionsreportedndingit
more dicult to institute required changes in care practices,
despite managerial support and authority delegation, the shi
from knowledge gain to knowledge translation may be related
to the characteristics of the individual. is nding indicates
that one-o education/training courses were insucient to
arm even senior nurses with the knowledge and skills they
needed for initiating and providing leadership in practice
change [, ]. As advised by these champions, additional
onsite mentoring and support by the study’s dementia nurse
specialist would have been very helpful in boosting their
condence in applying the strategies gained through the
education/training course.
Similartootherstudiesoftheperson-centredcare
model in long-term dementia care, managerial leadership
and cooperation, direct care sta understanding, knowledge,
acceptance, and perseverance in applying these approaches,
as well as GP and family acceptance, were considered essential
to implementation success [, ]. At times, champion lead-
ership for the study intervention was an issue for those from a
culturally and linguistically diverse (CALD) background who
had diculties with challenging the ambivalence of some of
the residents’ GPs and families with respect to the benet
of deprescribing antipsychotic medicines and replacing such
treatment with person-centred behavioural management
techniques. e authority provided to the champions by
senior management was identied by the champions to be a
key factor in addressing the reluctance of some families and
GPs to accept and support a nonpharmacological approach
to behaviour management. Consequently, the family’s and
GP’s understanding and acceptance of the person-centred
response to resident behaviours were an important fac-
tor in its implementation at the individual resident level.
Enabling the person-centred approach at the organisational
level in this substudy required dedicated education and
skill training for sta who felt insuciently empowered to
question medical decisions [, ]. In these circumstances,
the champions found it useful to engage the services of the
study’s psychogeriatrician to inuence the medical approach
to dementia in long-term care [, ].
e study ndings support the contention that person-
centred improvements in long-term care services are largely
a function of organisational structure, workforce capabili-
ties, organisational climate, communication structures, sta
readiness, and leadership [, , , , ]. One of the
strengths of the HALT study was the high level of organi-
sational support to enable champions and direct care sta
to implement and sustain person-centred care practices.
Examples of how managers supported the change process
included modifying work schedules, resident care priorities
and resident care plans, clear communication procedures
among the work teams, dedicating time for sta education
and supervision in practice, providing dierent practice
opportunities in relation to behaviour management, and
supporting adjusted treatments for participating residents.
As posited by Brooker [], concurrent consultation streams
of activity in knowledge translation need to occur with
development of person-centred responses to behaviour. is
concurrent process required active engagement of all stake-
holders, including resident families, GPs, and direct care
sta, in interpreting and translating the ndings to practice
improvement opportunities []. Such intensive activities
demanded additional work for the champions and a redef-
inition of their work roles and rescheduling of their time.
It also impacted on the job requirements and accountability
of the direct care sta. ese requirements are oen a
challenge with practice change at the organisational level
[, ].
While the study ndings are most informative in report-
ing details on how to introduce and sustain person-centred
approaches to behaviour management in long-term care,
they are limited to the experiences and recommendations
of the study champions who provided onsite leadership
andfacilitatedtheapproachwithdirectcaresta.An
acknowledged limitation is that the champion interviews
were undertaken by the project coordinator, which may have
introduced bias in the champions’ responses. Nevertheless,
these data provide detailed reections on the factors the
champions observed as having inuenced resident outcomes
with a person-centred approach and enhance the HALT
study’s contribution to the nonpharmacological management
of behaviour in dementia [, , , ]. Future studies on how
to best gain acceptance of this approach by resident families
and GPs are recommended. As well, a more comprehensive
view of the associated change practice factors and eects on
resident outcomes from the perspective residents’ families
and GPs, direct care sta, and care managers would have been
informative. While this is one of the substudy’s limitations,
these data are the subject of other HALT substudies and
future publications.
5. Conclusions
ere is strong evidence in the literature to suggest that
person-centred responses can help reduce behaviours in

 BioMed Research International
long-term care residents which care sta nd challenging,
in respect of being able to provide them with personal care
without resistance and in helping the person attain well-
being, despite physical, social, and cognitive limitations [–
]. ese ndings are similar to the experiences of the
HALT champions and are conrmed by the HALT study
results, which showed that at  months follow-up approxi-
mately three-quarters of the HALT study residents remained
deprescribed and showed no changes in behaviour [].
Translating the person-centred knowledge and skills learned
in the champions’ training course required a whole systems
approach to initiate and sustain care practice changes. is
was enabled by strong managerial support for the person-
centred approach to behavioural responses, empowerment
of the champions to drive and facilitate change at the site
level, and understanding, acceptance, and engagement with
the person-centred approach by direct care sta. Adherence
to the HALT deprescribing protocol [] and acceptance
of the person-centred responses to resident to behaviour
also relied on the willing cooperation of residents’ fami-
lies and GPs. eir cooperation provided nurses and care
stawithopportunitiestoadjustorganisationalsystems
and care practices to accommodate unique resident needs
and preferences, thereby more readily addressing issues
that triggered behaviours when providing care. Empowering
champions to facilitate onsite sta education and supervision
presented care sta with greater opportunities to reect on
and adjust care practices and communication strategies that
achieved better outcomes for residents. Further research is
now needed to collaborate with key stakeholders on how
best to promote the benets of person-centred care as a
viable alternative to antipsychotic medicines for long-term
care residents.
Data Availability
Some of the data are currently still being analysed for other
studies and will not be available until all articles are published.
Disclosure
estudysponsor(s)playednoroleinthedatacollection,
analysis, and interpretation of data, in the writing of the
article, or in the decision to submit the manuscript for
publication.
Conflicts of Interest
e authors declare that there are no conicts of interest
regarding the publication of this article. Over the last three
years, author Henry Brodaty has been on advisory boards of
or a consultant to Eli Lilly and Nutricia. His department has
received payment to participate in drug trials for Alzheimer’s
diseasebyTauerapeutics.AuthorsLynnChenowethand
Henry Brodaty have been recipients of grants for research
by the National Health and Medical Research Council and
Australian Department of Health and Ageing.
Authors’ Contributions
Lynn Chenoweth contributed to HALT study planning and
design, provided training and supervision to nurse cham-
pions in nonpharmacological prevention and reduction of
BPSD, contributed to data analysis and interpretation, and
led the writing of the manuscript; Tiany Jessop coordinated
the HALT study, contributed to data collection, analysis,
interpretation, and reporting, and contributed to writing the
manuscript; Fleur Harrison and Monica Cations undertook
participant recruitment and data collection, data entry, and
database management and contributed to data interpretation
and writing the manuscript; Janet Cook contributed to data
analysis and writing the manuscript; and Henry Brodaty
led the HALT planning, study design, recruitment, and
interpretation of the data and contributed to writing the
manuscript.
Acknowledgments
e HALT study was funded by the Australian Department
of Health under the Aged Care Service Improvement and
Healthy Ageing Grant Fund and supported by the Dementia
Centre for Research Collaboration, UNSW Sydney. e
authors acknowledge the contributions of other HALT study
team members, Perminder Sachdev, Brian Draper, Sarah
Hillmer, and Megan Heernan. e authors also thank
the contributions of the HALT study steering committee
members, Jacqui Close, Juanita Westbury, Lee-Fay Low, Aine
Heaney, Marie Alford, Stacy Wake, Janet Mitchel, Millie
Marinkovich, and Jenny Blennerhassett. Linda Nattrass,
Anne-Nicole Casey, Emily Trigge, and Tiany Chau are
acknowledged for their assistance with administration and
data entry.
Supplementary Materials
e HALT emergency behaviour response protocol was used
by the study’s nurses and champions when investigating,
interpreting, and responding to resident behaviour that
sta found extremely challenging, including person-centred
approaches. (Supplementary Materials)
References
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