Characteristics of the Sample
The 46 LTC staff who participated in the semi-structured interviews and focus groups held various roles in LTC. Demographics were provided by all but five staff members. Based on this information, there were 32 female and 7 male participants. One participant identified as neither female nor male, and another did not respond. The age of study participants varied, with a little over half of participants being under the age of 25 years (54%)., Study participants had a mean of 10.98 years (SD = 8.99) of experience working in a field related to dementia, with 54% reporting that they were ‘very involved’ in dementia care, 32% reporting ‘somewhat involved,’ and 10% reporting ‘not involved at all,’ See Table 1 for additional demographic characteristics.
Table 1
Demographic characteristics of staff participants (N = 41)
Characteristics | n (%) (Site 1) | n (%) (Site 2) |
Age in years | | |
Under 25 | 2 (8.7) | 0 (0.0) |
25–34 | 5 (21.7) | 3 (16.7) |
35–44 | 7 (30.4) | 3 (16.7) |
45–54 | 5 (21.7) | 7 (38.9) |
55–64 | 3 (13.0) | 5 (27.8) |
No response | 1 (4.3) | 0 (0.0) |
Gender | | |
Male | 4 (17.4) | 3 (16.7) |
Female | 17 (73.9) | 15 (83.3) |
Other | 1 (4.3) | 0 (0.0) |
No response | 1 (4.3) | 0 (0.0) |
Current role(s) | | |
Director of Care | 2 (8.7) | 1 (5.6) |
Registered Nurse | 2 (8.7) | 2 (11.1) |
Registered Practical Nurse | 6 (26.1) | 3 (16.7) |
Personal Support Worker | 6 (26.1) | 5 (27.8) |
Recreation Staff | 4 (17.4) | 1 (5.6) |
Housekeeper or Cleaner | 0 (0.0) | 2 (11.1) |
Cook or Kitchen Staff | 0 (0.0) | 1 (5.6) |
Other (e.g., Student Registered Practical Nurse, Maintenance, Life Transitions Coach, Coordinator of Volunteers, Resident Care Supervisor, Administrator) | 3 (13.0) | 3 (16.7) |
Employment Status | | |
Part-Time | 6 (26.1) | 5 (27.8) |
Full-Time | 17 (73.9) | 13 (72.2) |
Years of experience in field related to dementia | | |
0–2 | 6 (26.1) | 1 (5.6) |
3–5 | 7 (30.4) | 2 (11.1) |
6–10 | 4 (17.4) | 6 (33.3) |
11–15 | 1 (4.3) | 3 (16.7) |
Over 15 | 4 (17.4) | 6 (33.3) |
No Response | 1 (4.3) | 0 (0.0) |
Years of experience in current LTC home | | |
0–2 | 9 (39.1) | 4 (22.2) |
3–5 | 4 (17.4) | 1 (5.6) |
6–10 | 4 (17.4) | 7 (38.9) |
11–15 | 2 (8.7) | 6 (33.3) |
Over 15 | 4 (17.4) | 0 (0.0) |
Received training specific to dementia care | | |
No | 0 (0.0) | 2 (11.1) |
Yes | 23 (100.0) | 16 (88.9) |
Level of involvement in the planning or delivery of care for residents with dementia | | |
Not Involved at All | 1 (4.3) | 3 (16.7) |
Somewhat Involved | 9 (39.1) | 4 (22.2) |
Very Involved | 11 (47.8) | 11 (61.1) |
No response | 2 (8.7) | 0 (0.0) |
Overview of Findings
Themes were grouped under perceived outcomes of Namaste Care for residents living with advanced dementia and implementation facilitators and barriers in LTC. Study IDs were generated using an algorithm across both sites and used as identifiers for quotes. UM (unit manager), NUR (nurse), PSW (Personal Support Worker), and LTCS (LTC staff). See Table 2 for an overview of themes.
Table 2
Categories and themes of LTC home staff perspectives on the Namaste Care Program.
Categories | Themes |
1. Perceived Outcomes | a) Accommodates diverse needs and abilities of residents |
b) Provides social connections for families |
c) Creates partnerships in care |
d) Offers personalized care for residents |
2. Implementation Facilitators | a) Providing dedicated staff time |
b) Recruiting volunteer assistance |
c) Encouraging family involvement |
3. Implementation Barriers | a) Low staffing ratios |
b) Timing of Namaste Care sessions for families |
Perceived Outcomes.
Namaste Care was perceived by staff as a way to support the quality of life of residents with advanced dementia and promote social inclusion. The organizational need of LTC homes for a program like Namaste Care for residents living with advanced dementia was noted by all study participants. Namaste Care offered multiple benefits for families, residents, and staff. Themes were: (a) accommodates diverse needs and abilities of residents; (b) provides social connections for families; (c) creates partnerships in care; and (d) offer personalized care for residents.
Accommodates diverse needs and abilities of residents. Participants in management roles perceived that traditional programs (e.g., bingo, card games) offered in LTC are designed for residents with early to moderate dementia. “We would do our typical board games and things like that. But of course, the folks that are further along and have…severe Dementia or Alzheimer’s, they can’t participate in those things” (1UM 9). Residents with advanced dementia have diverse needs and abilities that were found to be supported through Namaste Care.
Thus, management participants strongly indicated the need to support the “hard to reach residents” (1UM 6) so that residents living with advanced dementia are not left “sitting in the hallways” (1UM 5) but are instead offered meaningful activities adapted to their level of physical and cognitive abilities. Namaste Care was viewed as being able to fill a gap in the current programming of LTC homes. Implementing such a program was considered important to “give them [residents with advanced dementia] a purpose” (1UM 9) and promote social inclusion. A staff member illustrated that these activities need not be complex, so long as it offers a highly personal experience to residents:
“It sounds maybe a bit silly, but I’ll give you an example of when I was in the day program and we had at one point a resident who would come down, and she [had] very severe Dementia and there wasn’t a lot we could get her to do, but…she had been a housewife, she had children, she loved doing things like folding clothes and stuff like that. So I used to go down to the laundry and just get a bunch of towels for her to fold and she would love that. So things that are so simple…it just gave her a purpose. Because she felt that she was doing something meaningful and that’s something that she always did, so I think that’s probably the number one for me” (1UM 9).
For this resident, having advanced dementia did not dismiss the opportunity for meaningful engagement through folding towels. However, staff perceived that most residents with advanced dementia were disproportionately vulnerable to social isolation—metaphorically and literally, sitting in the hallways. Therefore, staff saw Namaste Care as an outlet to offer residents a meaningful program designed specifically for advanced dementia.
Provides social connections for families. Managers, nursing staff, and PSW groups identified the Namaste Care program as a way of supporting family members to meaningfully connect with residents living with advanced dementia in LTC. Families were perceived by staff as having an important role in supporting the social inclusion of residents with advanced dementia. Managers also expressed the importance of facilitating the family-resident connection through Namaste Care:
“With family, we certainly can provide that education [on] how they can have a meaningful visit when they’re coming in to visit their loved one and what kind of activities they can utilize to make it a meaningful visit. So as far as the social relationships go, I think…family members will struggle and they often will say ‘I don’t know what to say or what to do when I come in,’ and then that’s where we can provide our expertise and help them come up with something” (2UM 7).
This is especially important as supervisors and managers identified that very few programs are geared towards family participation with residents in LTC homes (1UM 6). A staff elaborated:
“We have a family council. I don’t know if it’s a program. It’s sort of a mandated kind of engagement group that we are to have. Beyond that we probably don’t do that much [family engagement]. I think again it’s probably done more in informal ways” (1UM 6).
Namaste Care was perceived by staff as potentially offering a new and meaningful way for families to participate more directly in the unique community of the LTC home.
Creates partnerships in care. Participants consistently commented that Namaste Care was an appropriate and helpful way to facilitate partnerships in care. Being able to spend time co-delivering care allowed family caregivers and staff members to exchange observations and information they might not otherwise have had time to do. For instance, staff perceived that families participating in Namaste Care “may be able to provide an explanation or context to feelings that a resident with advanced dementia cannot express or explain” (1LTCS 2 Focus Group). One nurse stated that she was glad to be able to receive information from the family that she could then use to “provide content and more information to staff about certain [responsive] behaviours” (1NUR 3 Focus Group). Other staff members commented on how the reciprocal exchange of information in this venue generally helped to optimize residents’ care:
“I think for certain programs too it’s really helpful when the families are there because they can engage them. They sometimes listen to them better or they’re able to get them more active than we are at times…it’s really great to see and I think the family really enjoys it as well that we keep them up to date and really let them know what’s going. Because they really like to be engaged in those kinds of things. They look forward to going on outings with them and you know still being able to do those types of activities. I know sometimes it can be difficult to get them out in their car right, so it’s nice that they can come with us on the bus…in regards to the whole communication aspect, if you are dealing with a resident who can’t articulate feelings or anything along the lines of that, we can communicate with family and figure out different things that might trigger or help in the situation at hand” (1LTCS 4 Focus Group).
In this way, staff believed that Namaste Care is acceptable as a means to enhance partnerships between families and staff in providing care to residents. By including families in the care approach, they provide staff with valuable insights about the resident’s behaviours, actions, and thoughts. This may then allow staff to adjust their care for those residents to honour their values even if they cannot express it themselves.
Offers personalized care for residents. Managers described the Namaste Care program as an important tool to support personalization of care. Two aspects of Namaste Care helped to facilitate this: a small group environment allowing more one-on-one interactions, and adaptations to support people living with advanced dementia, allowing greater participation. One administrative staff member elaborates on this:
“Smaller group programming like you said so [residents] can have more one -on- one or one to three. So that’s why we like the Namaste Program. It’s a smaller group…they can get more individualized attention. Instead of being in a program where, you know, there’s ten people and they can’t toss a ball back, they can’t participate in the conversation. So that makes a difference there” (1UM 5).
Thus, despite being a group program, staff credited Namaste Care as an initiative that could achieve a higher degree of personalization than most group programming currently available in LTC. The acceptability of Namaste Care as an initiative for residents with advanced dementia was further suggested by staff who also felt the implementation of the program is beneficial for residents living with dementia who may otherwise spend much of their day alone.
Implementation Facilitators.
With regards to implementation facilitators, participants perceived that many facilitators were put in place to support the implementation of Namaste Care. Namaste Care was perceived as best delivered by: (a) providing dedicated staff time; (b) recruiting volunteer assistance; and (c) encouraging family involvement.
Providing dedicated staff time. PSWs and other LTC staff identified Namaste Care as a means to support their own social connections and meaningful engagement with residents living with advanced dementia. Staff members who delivered the program found it helpful to be provided with a block of time to deliver Namaste Care for residents and focus on providing meaningful engagement for residents. They stated that Namaste Care facilitates their ability to do the “extra little things” (1PSW 4 Focus Group) and provide the opportunity for more personal time with residents. In providing care in LTC, PSWs referenced:
“It’s an assembly line. This resident, this resident…there’s no downtime in between to just take that extra five minutes…[in Namaste Care], you get more personal one on one time with each [resident] if you’re…providing therapeutic touch for them. You get the one-on-one personal time with them. Because we…on a regular shift, we don’t have that time” (1PSW 4 Focus Group).
Further, relationships between residents and staff were strengthened through Namaste Care, as PWSs stated that “the more you know them [residents living with advanced dementia] the easier it is to work with them” (1PSW 4 Focus Group). These quotes demonstrate that often times, staff may not have the opportunity to fully understand and learn about their residents, though they have a strong desire to do so. Therefore, Namaste Care helps to slow down the pace of traditional shift work to provide a dedicated period for staff to meaningfully engage with residents with advanced dementia. This allows them to have an opportunity in providing such a type of care they may otherwise not have had a chance to engage in.
Recruiting volunteer assistance. Management staff identified volunteer help as one of the primary recommendations for successfully implementing the Namaste Care program. Staff also noted that volunteers benefit by feeling valued by the difference they make:
“[Volunteers] love the program and it’s what they come in to volunteer and do. Their passion is…they enjoy it, they love it, they love giving that individual care and they feel like they’re making a difference in each resident’s life” (1UM 8).
Therefore, there is a sense of team and reciprocity when volunteers work alongside the staff. The volunteer coordinator at one site expressed:
“Our staff are really thrilled with our volunteer participation because the more volunteers helping out with the program, the more people that can come out and attend the programs. Because you’ve got those extra hands to help with more residents. So, the attendance is higher if there’s more volunteers. I know people [get] more attention if there’s more volunteers assisting with programs because they can sit with people during programs. They can assist them more individually…The volunteer can comfort…other residents as well who need that one-on-one attention…we really rely on the help of volunteers” (1UM 8).
The use of more volunteers may be especially helpful as not only do they have the potential to build ‘workforce’ capacity for Namaste Care, but LTC staff noted that volunteers inherently “help a lot. It gives [residents] somebody else that they don’t see every single day come in to visit them. Somebody new to talk to that has different interests than a lot of the people here” (1LTCS 2 Focus Group), thus making each volunteer’s contribution all the more meaningful. However, some LTC staff shared challenges and reservations with volunteers, in particular, the difficulties in finding enough volunteers.
Encouraging family involvement. All staff emphasized that it is crucial to make the Namaste Care program an open program that families feel comfortable being a part of. Thus, staff recommended that Namaste be a program that actively encourages family members to be involved, which aligns with their overall perceptions of involving families in Namaste Care:
“I know a lot of [family members] don’t know about [Namaste], because…I’ve said, oh no you can sit in with them, go ahead. Try to engage [families] in that way and let them know. I think that would be helpful and just encourage them to come or if they have ideas. Things that maybe they want to present or participate in…instead of just getting consent for them to come. Just asking would you like to be involved? Do you want to sit in with your mom or loved one" (1 UM 10).
This collaboration can have a powerful impact that motivates families to participate and develop stronger relationships with care home staff. A management staff member summarizes the relationship as the following:
“[Namaste Care] does help with families and their perception that we’re doing everything that we can. And that perception is really important in the day to day. It builds the trust bank that we need to have with families. I think it can be a source of pride for the organization that we tried something innovative and different and new and we’ve stuck with it and figured it out and didn’t say no. We didn’t say not anymore. And that we’re always trying to change and grow and learn” (1UM 6).
Therefore, the family engagement in Namaste not only motivates future participation, but it importantly builds the trust family members have in the home taking action to address the gap in quality of care for residents with advanced dementia. As a result of this trust, some families used their time at a Namaste session as respite so that they may take a break from monitoring or advocating. LTC staff also seemed to encourage this collaboration and recommended that measures to bolster strong communication between the LTC home and families should be implemented to facilitate their participation in the Namaste Care program. However, clinical staff noticed that families would sometimes hesitate to join the Namaste sessions in fears of interrupting, which staff recommended should be mitigated by providing encouragement and reassurance for family participation early on.
Implementation Barriers.
Despite numerous perceived benefits of Namaste Care for residents, families, and staff, as well as many facilitators supporting program implementation, there were some barriers described by participants. These were: (a) low staffing ratios and (b) timing of Namaste Care sessions for families.
Low staffing ratios. While the nursing staff had positive impressions of Namaste Care, they were also initially apprehensive of the additional workload the program would create for staff. In the early implementation of Namaste Care, nurses collectively agreed that additional staff may be necessary to deliver the program:
“Staffing definitely would not be able to take this on…. We will support it…[but] the only way it could potentially happen…[is] say if you could add a part-time staff…to come in specifically for Namaste Care and you had two or three PSWs that were being paid to come in and provide this care” (2NUR 2 Focus Group).
PSWs also agreed that Namaste Care could improve the quality of life of residents with advanced dementia, but that the program should not rely on PSWs who were already responsible for meeting the usual care needs of residents. One PSW described:
“I feel like when you’re pulling us from the floor too, as much as I like that one-on-one interaction, my mind is still running and I’m saying okay I’m taking half an hour off, look at all this stuff I’ve got to go back [to] now” (1PSW 4 Focus Group).
Management was also concerned with this issue, with one administrative staff member remarking:
“Not to implement [Namaste Care] so much, but to sustain it – it’s been hard. It’s just getting on top of it for staffing. Who is going to run the program? The switches in schedules and times. Getting people there…pulling [staff] off the floor I know is only a half an hour [at a time], but pulling them off the floor when we’re already so stretched. Like we’re already thin as it is, right…I don’t want to pull them away if we are already seriously understaffed” (1UM 10).
Despite staff concerns regarding workload conflicting with the implementation of the program, homes were still able to deliver the program by involving staff from various disciplines and assigning roles to lessen the burden of program delivery. A simple example such as transporting residents to the Namaste Care room exemplifies this: “Everyone is kind of used to pitching in and getting people to where they need to go…we can make sure there’s volunteer support and that sort of thing” (2UM 4).
Timing of Namaste Care sessions for families. Namaste Care was delivered at fixed times in the morning and afternoon in the LTC homes. This made it difficult for family members who were not available at those times to attend. It was said that “a lot of times [Namaste] is in the morning…a lot of the family members, they have young families. They work. They cannot be here” (1PSW 4 Focus Group). Therefore, the nursing staff recommended that the time and setting of the Namaste Care program should be fluid to meet the individual needs of residents living with dementia. In particular, some clinical staff recommended that Namaste Care sessions be delivered in the evenings and weekends, when families are presumably more likely to be available to attend. However, with evening sessions, this also raised additional challenges, as staff perceived that:
“With the evening activities you can’t get anybody to go right? They are ready for bed…The activity girls, by the time they come, [the residents] are all in bed. Because everybody wants to go to bed, and I don’t blame them” (1PSW 4 Focus Group).
However, even if families were able to attend, some staff believed that the length of one session was too short for family members to justify the commute. As a community centre staff explained:
“With the Namaste Program…it’s such a small window. It’s only half an hour in the morning and then half an hour in the evening, or afternoon. So it would be hard [for families] to get out, come here for the half an hour, and then back to what you were doing before” (1LTCS 2 Focus Group).
Therefore, despite staff emphasizing the importance of family engagement in Namaste Care, they recognized that the timing and duration of these sessions may not align with what family members are able to commit.