What works in delivering dementia education or training to hospital staff? A critical synthesis of the evidence

Background: The quality of care delivered to people with dementia in hospital settings is of international concern. People with dementia occupy up to one quarter of acute hospital beds, however, staff working in hospitals report lack of knowledge and skills in caring for this group. There is limited evidence about the most effective approaches to training hospital staff on dementia. Objective: The purpose of this literature review was to examine published evidence on the most effective approaches to dementia training and education for hospital staff. Design and review methods: The review was conducted using critical synthesis and included qualitative, quantitative and mixed/multi-methods studies. Kirkpatrick’s four level model for the evaluation of training interventions was adopted to structure the review. Data sources: The following databases were searched: MEDLINE, PsycINFO, CINAHL, AMED, British Education Index, Education Abstracts, ERIC (EbscoHost), The Cochrane Library-Cochrane reviews, Economic evaluations, CENTRAL (Wiley), HMIC (Ovid), ASSIA, IBSS (Proquest), Conference Proceedings Citation Indexes (Web of Science), using a combination of keyword for the following themes: Dementia/Alzheimer’s, training/education, staff knowledge and patient outcomes. Results: A total of 20 papers were included in the review, the majority of which were low or medium quality, impacting on generalisability. The 16 different training programmes evaluated in the studies varied in terms of duration and mode of delivery, although most employed face-to-face didactic techniques. Studies predominantly reported on reactions to training and knowledge, only one study evaluated outcomes across all of the levels of the Kirkpatrick model. Key features of training that appeared to be more acceptable and effective were identified related to training content, delivery methods, practicalities, duration and support for implementation. Conclusions: The review methodology enabled inclusion of a broad range of studies and permitted common features of successful programmes to be identified. Such features may be used in the design of future dementia training programmes, to increase their potential for effectiveness. Further research on the features of effective dementia training for hospital staff is required

Monitoring and improving the quality of person-centred care in health and social settings using Dementia Care Mapping (DCM): Staff experiences of implementation barriers and supports

Dementia Care Mapping (DCM) is a person-centred care quality monitoring and improvement tool used for nearly 20 years in formal dementia care settings and there are thousands of people trained in its use internationally. However, little is known about if and how DCM is used in practice or regarding application of inter-rater reliability checks to ensure data quality. This study aimed to explore the application of DCM in practice in the UK. A mixed methods design including an on-line survey and in-depth, semi-structured interviews was employed. There were 98 survey respondents, representing 71 health and social care, University/research and training/consultancy organisations. Twenty-one people participated in the semi-structured interviews. Fifty-nine percent of survey respondents had used DCM since completing training. Those working in clinical roles and in health and social care provider organisations were least likely to have used DCM. A range of barriers and supports to use of DCM in practice after training were reported, including lack of management support and time. The majority of those who had used DCM also conducted inter-rater reliability checks at least once per year or more frequently. Of the 20% who did not the main barriers to this were absence of someone to conduct the checks with and lack of time and resources. The study has shown that it is possible to apply an evidence-based quality monitoring and improvement tool such as DCM to support implementation of person-centred care in practice, despite widespread limitations on time and resources as well as identifying a range of setting conditions that can help or hinder implementation

Impact of a person-centred dementia care training programme on hospital staff attitudes, role efficacy and perceptions of caring for people with dementia: A repeated measures study.

Background: People with dementia occupy up to one quarter of acute hospital beds. However, the quality of care delivered to this patient group is of national concern. Staff working in acute hospitals report lack of knowledge, skills and confidence in caring for people with dementia. There is limited evidence about the most effective approaches to supporting acute hospital staff to deliver more person-centred care. Objectives: This study aimed to evaluate the efficacy of a specialist training programme for acute hospital staff regarding improving attitudes, satisfaction and feelings of caring efficacy, in provision of care to people with dementia. Design: A repeated measures design, with measures completed immediately prior to commencing training (T1), after completion of Foundation level training (T2: 4-6 weeks post-baseline), and following Intermediate level training (T3: 3-4 months post-baseline). Setting: One NHS Trust in the North of England, UK. Participants: 40 acute hospital staff working in clinical roles, the majority of whom (90%) were nurses. Methods: All participants received the 3.5 day Person-centred Care Training for Acute Hospitals (PCTAH) programme, comprised of two levels, Foundation (1/2 day) and Intermediate (3 days), delivered over a 3-4 month period. Staff demographics and previous exposure to dementia training was collected via a questionnaire. Staff attitudes were measured using the Approaches to Dementia Questionnaire (ADQ), satisfaction in caring for people with dementia was captured using the Staff Experiences of Working with Demented Residents questionnaire (SEWDR) and perceived caring efficacy was measured using the Caring Efficacy Scale (CES). Results: The training programme was effective in producing a significant positive change on all three outcome measures following intermediate training compared to baseline. A significant positive effect was found on the ADS between baseline and after completion of Foundation level training, but not for either of the other measures. Conclusions: Training acute hospital staff in Intermediate level person-centred dementia care is effective in producing significant improvements in attitudes towards and satisfaction in caring for people with dementia and feelings of caring efficacy. Foundation level training is effective in changing attitudes but does not seem to be sufficient to bring about change in satisfaction or caring efficacy

Implementing Dementia Care Mapping as a practice development tool in dementia care services: A systematic review

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, 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 criteria 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 implementation processes. Assessment of study quality was conducted using the Mixed Methods Appraisal Tool (MMAT). 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, with effective leadership for DCM within the implementing organisation/unit and in organizations that already have a person-centred 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

Experiences and support needs of informal caregivers of people with multimorbidity: a scoping literature review

Objective: Describe and synthesise existing published research on the experiences and support needs of informal caregivers of people with multimorbidity. Design: Scoping literature review. Primary database and secondary searches for qualitative and/or quantitative English-language research with an explicit focus on informal carers of people with multimorbidity (no date restrictions). Quality appraisal of included papers. Thematic analysis to identify key themes in the findings of included papers. Results: Thirty-four papers (reporting on 27 studies) were eligible for inclusion, the majority of which were rated good quality, and almost half of which were published from 2015 onwards. The review highlights common difficulties for informal carers of people with multiple chronic illnesses, including practical challenges related to managing multiple health care teams, appointments, medications and side effects, and psychosocial challenges including high levels of psychological symptomatology and reduced social connectedness. Current gaps in the literature include very few studies of interventions which may help support this caregiver group. Conclusion: Interest in this research area is burgeoning. Future work might fruitfully examine the potential benefits of audio-recorded health care consultations, and digitally-delivered psychosocial interventions such as online peer support forums, for supporting and enhancing the caring activities and wellbeing of this caregiver group

Components of impactful dementia training for general hospital staff: a collective case study

Background and objectives: People with dementia occupy around one quarter of general hospital beds, with concerns consistently raised about care quality. Improving workforce knowledge, skills and attitudes is a mechanism for addressing this. However little is known about effective ways of training healthcare staff about dementia. This study aimed to understand models of dementia training most likely to lead to improved practice and better care experiences for people with dementia, and to understand barriers and facilitators to implementation. Method: A collective case study was conducted in three National Health Service Acute Hospital Trusts in England. Multiple data sources were used including interviews with training leads/facilitators, ward managers and staff who had attended training; satisfaction surveys with patients with dementia and/or carers; and observations of care using Dementia Care Mapping. Results: Interactive face-to-face training designed for general hospital staff was valued. Simulation and experiential learning methods were felt to be beneficial by some staff and stressful and distressing by others. Skilled delivery by an experienced and enthusiastic facilitator was identified as important. Staff identified learning and practice changes made following their training. However, observations revealed not all staff had the knowledge, attitudes and skills needed to deliver good care. Patient and carer satisfaction with care was mixed. A major barrier to training implementation was lack of resources. Supportive managers, organisational culture and strong leadership were key facilitators. Conclusion: Dementia training can lead to improved care practices. There are a range of key barriers and facilitators to implementation that must be considered

An audit of dementia education and training in UK health and social care: a comparison with national benchmark standards.

BACKGROUND: Despite people living with dementia representing a significant proportion of health and social care users, until recently in the United Kingdom (UK) there were no prescribed standards for dementia education and training. This audit sought to review the extent and nature of dementia education and training offered to health and social care staff in the UK against the standards described in the 2015 Dementia Training Standards Framework, which describes the knowledge and skills required of the UK dementia workforce. METHODS: This audit presents national data concerning the design, delivery, target audience, length, level, content, format of training, number of staff trained and frequency of delivery within existing dementia training programmes offered to health and social care staff. The Dementia Training Standards Framework was used as a reference for respondents to describe the subjects and learning outcomes associated with their training. RESULTS: The findings are presented from 614 respondents offering 386 training packages, which indicated variations in the extent and quality of training. Many training packages addressed the subjects of 'person-centred care', 'communication', 'interaction and behaviour in dementia care', and 'dementia awareness'. Few training packages addressed subjects concerning 'pharmacological interventions in dementia care', 'leadership' and 'end of life care'. Fewer than 40% of The Dementia Training Standards Framework learning outcomes targeted to staff with regular contact with people with dementia or in leadership roles were covered by the reported packages. However, for training targeted at increasing dementia awareness more than 70% of the learning outcomes identified in The Dementia Training Standards Framework were addressed. Many training packages are not of sufficient duration to derive impact; although the majority employed delivery methods likely to be effective. CONCLUSIONS: The development of new and existing training and education should take account of subjects that are currently underrepresented and ensure that training reflects the Training Standard Framework and evidence regarding best practice for delivery. Lessons regarding the limitations of training in the UK serve as a useful illustration of the challenge of implementing national dementia training standards; particularly for countries who are developing or have recently implemented national dementia strategies

Optimising Intervention Implementation in the EPIC trial

The DCM™ EPIC trial requires participating care homes to identify two staff members willing to be trained in the DCM™ intervention and thereafter implement three DCM ‘mapping cycles’ during the trial. These staff are known as ‘mappers’. This is no small undertaking, and early pilot work highlighted the need to include additional measures to enhance adherence to some elements of intervention uptake and delivery. Various strategies were thus implemented which comprise: a) provision of enhanced information to prospective staff mappers, b) requirement for staff to detail their understanding of DCM™, c) DCM™ expert contact with mappers ahead of randomisation to ensure eligibility and suitability, d) an expert-supported first cycle of mapping, e) review of mapper and expert feedback after the first cycle to ensure areas of concern can be addressed prior to the next cycle, f) CTU contact with mappers to flag the timing of the next mapping cycle, and address any concerns. To achieve the above, trials unit staff act as a central point of contact, reviewing mapper consent and materials, monitoring each stage of the process and contacting DCM™ experts and the Chief Investigator to flag issues and problems in a timely manner. Although enhancing intervention compliance in this way can be seen to be altering the implementation of the intervention and thus reducing its generalizability, it will be discussed that intervention optimisation is necessary to minimise the likelihood of negative results attributable to poor implementation rather than intervention ineffectiveness

The influence of care home managers on the implementation of a complex intervention: Findings from the process evaluation of a randomised controlled trial of Dementia Care Mapping

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

A collective case study of the features of impactful dementia training for care home staff

Background: Up to 80% of care home residents have dementia. Ensuring this workforce is appropriately trained is of international concern. Research indicates variable impact of training on a range of resident and staff outcomes. Little is still known about the most effective approaches to the design, delivery and implementation of dementia training. This study aimed to investigate the features and contextual factors associated with an effective approach to care home staff training on dementia. Methods: An embedded, collective case study was undertaken in three care home provider organisations who had responded to a national training audit. Data collected included individual or small group interviews with training leads, facilitators, staff attending training, managers, residents and their relatives. Observations of care practice were undertaken using Dementia Care Mapping. Training delivery was observed and training materials audited. A within case analysis of each site, followed by cross case analysis using convergence coding was undertaken. Results: All sites provided bespoke, tailored training, delivered largely using face-to-face, interactive methods, which staff and managers indicated were valuable and effective. Self-study booklets and on-line learning where were used, were poorly completed and disliked by staff. Training was said to improve empathy, knowledge about the lived experience of dementia and the importance of considering and meeting individual needs. Opportunities to continually reflect on learning and support to implement training in practice were valued and felt to be an essential component of good training. Practice developments as a result of training included improved communication, increased activity, less task-focussed care and increased resident well-being. However, observations indicated positive well-being and engagement was not a consistent experience across all residents in all sites. Barriers to training attendance and implementation were staff time, lack of dedicated training space and challenges in gaining feedback on training and its impact. Facilitators included a supportive organisational ethos and skilled training facilitation. Conclusions: Effective training is tailored to learners’, delivered face-to-face by an experienced facilitator, is interactive and is embedded within a supportive organisational culture/ethos. Further research is needed on the practical aspects of sustainable and impactful dementia training delivery and implementation in care home settings