Stakeholders discussed a range of issues influencing the utility and implementation of the EIT-4-BPSD. Table 5 illustrates 11 key categories that emerged from codes organized within in each RE-AIM element.
Table 5. Summary of Key Categories Affecting EIT-4-BPSD Program Implementation within RE-AIM Framework
RE-AIM Element
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Category
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Factors influencing feasibility and utility of EIT-4-BPSD implementation
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Exemplar Quote
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Reach
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Family
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Family as essential member of care team
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I learn a lot about my residents from families. (3-308)
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Staff
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Interdisciplinary team members
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Reach out to all of your team members, not just nursing. Everyone can help. (2-306)
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Organizational
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Nursing home motivation for study engagement
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Although we have many years of experience working with this population, (there were) the failed attempts to get results... (welcomed) a new approach and maybe some education. (3-314)
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Effectiveness
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Staff Outcomes
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Changes in staff behaviors
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We also have staff doing things with versus just for residents and we are trying to match activities with resident preferences…nursing assistants are doing more teaching and cueing. (1-108)
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Changes in staff attitudes
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We are going towards a prevention mindset to identify and eliminate triggers. It helped them [staff] look at behavior in a different way. (3-122)
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Staff empowerment
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Staff have gotten excited about effectiveness of non-pharmacologic interventions, [they] feel empowered. (1-202)
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Environmental Outcome
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Changes to the physical environment to promote function and well-being
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Definitely focusing more on personal preferences of patients. We have also done things like “soften up the environment.” (1-108)
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Resident Outcome
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Decrease in BPSD
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Our residents’ behaviors have gone down since the study. (3-314)
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Adoption
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Utility of EIT Resources
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Brainstorming exercise
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The brainstorming was really helpful as it helped us to see things in a different way. (2-112)
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DICE model (Describe, Investigate, Create, Evaluate)
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They learned to use DICE and used this to figure out the situation and intervene. (2-114)
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Nursing Home Toolkit
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Nursing home toolkit website...it was helpful, but we did not utilize too much - enjoyed sundowning tidbit. (2-304)
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Tidbits
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We had education sessions using the weekly tidbits, very informal, positive response… (3-310)
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Staff education
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I think education is really the most important thing. (2-210)
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Staff contests
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The contests were very helpful and got the staff motivated and engaged in providing behavioral interventions to residents. (3-122)
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Behavioral observations
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It was a really nice way to give peer-peer observations… first couple of times I found it difficult because I thought I could not intervene, but I learned I could it gave an opportunity to model good responses. It was a real-life example of how to model behavior. (3-310)
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Huddles
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…our huddles [are] where we talk about specific residents, their behaviors and what we can do to change their behaviors. (3-314)
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Stakeholder meetings
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Stakeholder meeting… we came to monthly meeting open to all staff, much more effective then random sitting next to one another but opportunity for everyone to be equals when approaching this topic. (2-304)
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Interventionist as role model
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…really liked…having the research nurse there and doing hands on activities with the staff. (1-108)
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Care plan review
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It was very eye-opening…It gave us a chance to look and go through and make sure care plans are accurate. We have written more customized care plans and moved away from check boxes. Extra time to look at and reassess to improve was helpful (3-310)
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Environment and Policy Assessment
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…we do have corporate office, and a lot of the policies are handed to the site so you can make suggestions but it is not something you can anticipate a change…so you don’t want to spend time on it. (2-304)
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Implementation
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Barriers
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Physical environment
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The environment was a little bit of a barrier for us-no area for open walking. (2-112)
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Nursing home regulations
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Worried about HIPPA and getting staff to look at and use this material. (1-106)
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Finances
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Many restraints an issue- not able to get finances. (3-308)
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Competing demands
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I was promoted which gave me more responsibilities, so I did not have as much time to focus on (implementation) goals. (3-310)
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Staffing levels/turnover
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We were working with short staff so a lot of the behaviors they were likely not charting because we were short. (3-314)
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Facilitators
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Motivators for change
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I think in the beginning we were having a lot of residents with behavioral disturbances and we did not know how to non-pharmacologically manage those residents – that was our largest strive at the time. (2-210)
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Manager/leadership engagement
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The manager dedication, house supervisor dedication, and the interventionist following through with what the study offered were all factors to the success of the study. (3-128)
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Staff buy-in
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Getting buy-in from staff outside of the stakeholder group. They are all interested, they wanted to learn. The staff genuinely care about our residents. (2-306)
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Access to recreational activities for residents
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We made major inroads by establishing that we needed an activities room for the residents. A place that they could go to and engage in some of the activities. We now have that room! (1-106)
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Care Process Adaptations
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Staff-staff and leadership communication
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Goal number one, we were in the process, but this put an emphasis on ensuring that all staff had access to information. This has made information more accessible. (3-310)
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Care planning process
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We started a new behavioral care planning process. We meet weekly to take a deeper dive into why behaviors are occurring, identify and eliminate triggers. (2-306)
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Quantity and quality of resident recreational activities
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Cutting down on psychotropics. Increasing activities. We have more resident focused groups now like a men’s group. For the women we had a mother/daughter tea... (2-306)
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Formal process for staff engagement
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December in-service was highest attended, very physical in-service where there was competition…they were so engaged…and part of that was that they had to say something important…There was acceptance of time spent… It was worth it. (2-304)
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Maintenance
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Future Planning
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Specific organizational goals
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[This study is] an attempt for our organization to improve the well-being of our residents through specific organizational goals. (3-308)
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Remain on Tidbit list
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We want to keep getting the tidbits. (2-120)
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Commit to provide in-services
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Way to continue in-services…Choose 3 staff to commit to provide in-services. Pick a topic –give open forum to follow-up on the education that received –very positive to continue with all the staff. (2-304)
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Plan for continued meetings
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... we still keep the once a month stakeholder meeting. (2-304)
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Measures of success
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... we started out thinking about measurement and how to improve our quality indicators, after consulting it seemed that we changed to how we can increase moments of joy as measurement of success (3-308)
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Reach
Reach explored characteristics of those engaged in the implementation strategy, including the reasons for enrolling in the study, as compared to those who we intended to engage (9). Data represented a wide range of stakeholders who engaged in the implementation strategy and reasons for participation in the study from an organizational and individual stakeholder perspective.
Participants described why their NH engaged in the implementation of EIT-4 -BPSD. Some participants described a shared, overt dissatisfaction with the current state of dementia care and a need for more effective approaches.
Although we have many years of experience working with this population, (there were) the failed attempts to get results...(welcomed) a new approach and maybe some education. (3-314)
Others described organizational commitments to formalize processes around BPSD assessment and care planning. Desired outcomes included enhanced communication and staff-resident relationships, and improved resident well-being and quality of life. Administrators’ were described as key people who advocated for organizational engagement and innovation and were motivated to initiate/sustain academic partnerships to increase resources for care delivery. This motivation was based on past positive experiences and outcomes when working with university research studies. One participant stated:
All facilities that are invited to participate in dementia research studies should take advantage of it because of receiving extra support, education, and good tips. (2-118)
Participants described characteristics of EIT-4-BPSD leading to NH engagement including: its participatory nature which was perceived to empower (“give a voice” 3-308) staff and align with organizational philosophy of care; and the holistic nature of EIT-4 BPSD, which emphasizes emotional well-being, physical function, and preference congruence.
Participants described staff from various disciplines and departments who participated in implementation activities. They included staff directly recommended by the study protocol such as direct care nursing staff (i.e., nursing assistants, licensed practical nurses, charge nurses, unit managers, nurse educators), unit clerks, activities staff, occupational therapy interns, dietary aides, medical directors, administrator, director of nursing, housekeeping, maintenance, and human resources. Non-nursing team members were described as helpful when cross-trained to tasks that were typically outside of their job. For example, in one NH, nursing assistants lacked time to complete observations of care interactions (EIT-4-BPSD step 4) so they trained unit clerks to complete the observations. Based on experiences like this, participants suggested that staff from all disciplines and shifts be included in the implementation strategy. In contrast, some participants reported that implementation of EIT-4-BPSD was not a priority due to other pressing demands. As one participant reported, I felt like we had so many problems and that this was another layer (3-314).
Family members were described as key informants, essential to implementation activities. Participants indicated a need for family education to support non-pharmacological approaches to BPSD. In some NHs family members were involved in implementation activities such as huddles, individual preference-based activities with residents, and education programs. Family member involvement led to better perceived collaboration, communication, and psychosocial support between NH staff and family members. However, in some cases, family was described as creating barriers. For example, in one NH, the stakeholder team identified a need to make environmental changes to include sensory stations in the hallways to promote walking. This change needed family council approval; however, the stakeholder team could not effectively engage the council to discuss this proposal and the initiative failed.
Effectiveness
Effectiveness explored the positive benefits and negative effects of the implementation strategy (9). Participants identified positive and negative effects on staff, environmental, and resident outcomes.
Staff Outcomes
Staff outcomes included changes in staff behaviors and attitudes, and staff empowerment. Participants most often identified increased individualized care for residents as a result of participation in EIT-4-BPSD. Participants discussed avoiding psychoactive medication administration, promoting self-care, providing preference-based activities, and using therapeutic communication including modeling and cueing for residents. Staff were described as doing things “with” residents rather than “for” residents, purposefully matching residents’ preferences with activities to reduce unwanted behaviors and encourage resident well-being. This approach resulted in rippling effects throughout the organization. For example, one participant described:
…a resident that would never come out of his room. They brought him to the day room
and engaged him in music and now he asks for it every day. This has spread through the facility and others ask for music as well. (2-114)
New staff behaviors were contrasted with past habits of treating behavioral symptoms with medications or ignoring the resident behavior altogether. Participants attributed the changes in staff actions and behaviors to use of the DICE (Describe, Investigate, Create, Evaluate) model (See Table 3).
Participants suggested that changes in staff behaviors resulted from fundamental changes in staff attitudes toward a mindset of identifying and eliminating triggers rather than simply reacting to BPSD or ignoring them altogether. They suggested brainstorming activities, interdisciplinary problem solving, and on-going education and role modeling (by champions and research facilitator) were helpful for staff to reframe residents’ behaviors. This attitudinal change was also associated with a sense of empowerment. As one participant stated:
Staff have gotten excited about effectiveness of non-pharmacologic interventions, [they] feel empowered. (1-202)
Empowerment was described as professional growth of nursing assistants and other staff to a place where staff feel valued and competent to contribute, intervene, and even become mentors to others.
Conversely, some participants described discouragement when their ideas were not implemented. For example, one participant rationalized the stakeholder team’s failure to empower staff:
I think the failure was on the part of the facility not the project itself. When [we] are able to come up with an idea and then make it happen then you are empowered. (2-210)
Environmental Changes
Some participants identified changes to the physical environment to promote function and well-being as an implementation outcome, although a few participants did not see the value of environmental modifications. Participants discussed making changes to the physical design and milieu to “soften” the environment and make it more homelike. This included changing lighting, adding new fixtures, playing music, creating activity rooms and/or transforming dayrooms with new paint and activity/life stations for residents based on residents’ past jobs and hobbies and tailored to residents’ current level of function. Some participants expressed frustrations with a lack of progress toward environmental change goals when corporate staff or administrators were not supportive of the change or when there were structural issues that could not be addressed (e.g., long hallways and lack of quiet space).
Resident Outcomes
Discussed less often, participants perceived a decrease in residents’ BPSD (i.e. calmer, less agitation) resulting from EIT-4-BPSD. This was attributed to resident engagement in activities through life stories and preferences. One participant described a creative way to use a resident’s life story to improve afternoon symptoms of agitation:
I had a resident who used to have a highball every afternoon. I started giving her some ginger ale …. her afternoon behavior changed/improved. It calmed her right down. (2-114)
Another participant attributed a general decrease in BPSD among residents to knowing who people are and providing a meaningful and stimulating environment:
A lot of behaviors in long-term care stem from boredom and lack of stimulation…presence of increased activities…boredom has decreased…improvement in behaviors. (2-204)
Adoption
Adoption explored the characteristics of where the implementation strategy was applied and who in the organization applied it (9). Participants discussed using various resources and tools provided by the study team and their value in promoting uptake of EIT-4-BPSD. With few exceptions, participants described the stakeholder team as the person(s) using EIT-4-BPSD resources within their NH.
Brainstorming Exercise
Conducted as part of the initial 4-hour training, participants described the brainstorming session as a valuable tool to help them think differently about practice issues in their NH. This exercise yielded site-specific implementation goals.
Use of the DICE Model.
Participants reported DICE as a valuable tool to challenge thinking about how to systematically address behaviors. Stakeholders placed information about the DICE model on every unit. Participants also described direct caregivers and social services staff using the model to figure out BPSD situations and intervene.
Nursing Home Toolkit Website
The Nursing Home Toolkit (14) was described as a valuable resource for defining behaviors and accessing “Tidbits”. Stakeholders expressed a desire to spend more time looking at the toolkit. Without elaboration, others reported that they did not use it much and it was not “geared toward [Certified Nursing Assistants] CNAs” (1-202).
Weekly Tidbit Emails
Participants frequently reported using the Tidbits as a valuable tool to educate and motivate staff (very informal…. positive response, 3-310). Tidbits were printed, put into notebooks, and posted on units to encourage staff to refer to them. Participants described value in providing ongoing education about BPSD when orienting new staff and in routine in-servicing of existing employees.
Staff Education
Participants suggested that education around BPSD helped staff learn tips and techniques to address behavioral situations with residents. Participants found that this was particularly helpful when it was conducted face-to-face with hands on exercises and role plays and included staff from all departments and disciplines in the NH.
Staff Contests
Contests were described as valuable ways to engage staff in providing BPSD interventions for residents. They also raised awareness of BPSD and promoted shared ideas to support resident well-being.
Behavioral Observations
Observations of staff-resident interactions were conducted by stakeholder team members, organizational leaders and management, staff peers, and unit clerks. Participants described pragmatic behavioral observations as a valuable way to provide feedback to staff, identify staff that were appropriate for dementia care units, track occurrence of behaviors, and evaluate progress toward reaching study goals to reduce BPSD. Some participants felt the observational tool was not user friendly.
Huddles
Huddles, brief “stand-up’ meetings, were described as a valuable, efficient tool to discuss specific residents, their BPSD, life histories and preferences, and what the team can do to promote resident well-being. Some sites conducted huddles weekly and others monthly.
Stakeholder Meetings
Participants described monthly stakeholder meetings as a valuable space for consulting and following-up on a goal or approach to make the change a reality. The site champion would organize the stakeholder meeting and attempt to include representatives from all departments. In some cases, lack of administrator engagement and time constraints made it difficult for the champion to organize stakeholder meetings, and some stakeholders suggested that they did not see any benefit from them at all.
Interventionist as Role Models
Participants described working with the research facilitator to provide: hands-on activities and education to staff and site champions; “fresh eyes” in challenging BPSD situations; a listening ear and continual encouragement to team members; a structure for team members to track tasks toward goal attainment; an education with family members. Participants valued the research facilitators, often suggesting they would have liked more “face to face time” (1-108) with them. Stakeholders acknowledged the Environment and Policy Assessment, conducted by the research facilitator and champion, but did not describe it as integral to implementation.
Care Plan Review
Stakeholders discussed reviewing care plans as a valuable way to individualize care. They suggested care plan audits-review of care plans using a study provided checklist-were useful for evaluating completeness and enhancing person-centered approaches.
Implementation
Implementation explored how consistently EIT-4-BPSD was delivered, how it was adapted(9), and barriers and facilitators to implementation (15). Three categories emerged: barriers, facilitators, and care process changes.
Barriers
Participants described barriers related to implementing and adhering to all EIT-4-BPSD protocol components. These included the physical environment, NH regulations, finances, competing demands, and staffing levels/turnover. Lack of physical space impeded stakeholder efforts to make the environment more person-centered, i.e., homelike, and reflective of the residents’ preferences and backgrounds. Regulations curtailed the sharing of personal resident information among staff and union contracts prohibited peer-peer behavioral observations, which were designed to provide feedback on the implementation of the care plan. Participants described finances as a barrier when they were unable to secure funding for organizational strategies. For example, one participant described the stakeholder teams’ goal to add signage within the unit to facilitate wayfinding, which was not met due to an inability to secure funding.
Participants often reported competing demands on staff time as a barrier to implementation. In these cases, the approach to care was described as time focused and task oriented and staff were described as stressed and overwhelmed with trying to balance BPSD approaches (e.g. adapted communication and therapeutic activities) with meeting the residents’ personal care needs. Implementation activities were viewed as “extra” activities that staff had to balance with job demands. For some, clinical issues and surveys took precedence over participation in implementation activities (e.g., stakeholder meetings and education). One participant described demands associated with changing levels of responsibilities detracting from time needed to work on implementation goals:
I was promoted which gave me more responsibilities, so I did not have as much time to focus on (implementation) goals. (3-310)
Also frequently discussed were issues in staffing levels and turnover. As one
participant reported:
There were challenges due to turnover in key staff, plus the day to day struggle of juggling priorities. (2-306)
Participants from NHs that identified problems with staffing levels also described turnover in administrative, activities, social work, and direct-care staff occurring as frequently as every three months. Some reported using a high volume of agency staff and regular staff working double shifts resulting in worker fatigue and burnout. This made it difficult to hold staff accountable to maintain care consistency. It also required stakeholder teams to continually repeat training on BPSD and at times required a change in site champion. Based on perceived poor implementation, participants recommended that NHs “get the right champion from the beginning” (2-210). Participants explicated ideal characteristics of successful champions as people who are strong, passionate about dementia care, and able to make change.
Participants opined that staff turnover was a good thing, by removing staff that “just don’t make the cut” (1-104). One participant described a decrease in BPSD resulting from removing staff that were unsuitable for the memory care unit. Another described turnover offering new opportunities for other leaders to emerge and take-on responsibilities to disseminate the intervention. This was illustrated by one participant, describing the administrator’s employment termination: Once we lost the administrator piece, it gave us more responsibility to get the word out. (1-206). Conversely, participants who described positive staffing levels with tenured administrators, also reported that the program was achievable due to fewer competing demands on staff time and less staff burnout.
Facilitators
Discussed more frequently than barriers, participants described several workforce characteristics promoting consistent adherence to EIT-4-BPSD. Implementation facilitators included motivators for change, manager/leadership engagement, staff buy-in, and access to recreational activities. Participants discussed motivators for change as reasons why it was important to participate in the study and implement the intervention strategies. These varied between staff and leadership. Staff were described as having a desire to learn behavioral approaches to reduce negative effects of living with dementia for residents and thus provide quality dementia care and regulatory compliance. One stakeholder described this as:
I think in the beginning we were having a lot of residents with behavioral disturbances and we did not know how to non-pharmacologically manage those residents – that was our largest strive at the time. This was resulting in mandatory reporting to the state. (2-210)
Closely related, participants expressed staff motivations to improve the residents’ quality of life.
So many opportunities to learn new and different ways to work with residents…this was real-life and real-time…we are coming to the table with specific issues and leaving with the highest quality of life. (2-304)
Participants described managers as the driving force behind consistent participation and follow through with implementation activities. Participants described engaged managers as people who were dedicated and willing to improve dementia care:
The manager dedication, house supervisor dedication, and the interventionist following through with what the study offered were all factors to the success of the study. (3-128)
Engaged leaders provided encouragement and support to staff with material resources and decision-making and stayed fully engaged in implementation activities (e.g. stakeholder meetings). Participants also indicated staff buy-in was critical to implementation success. Staff buy-in was described as the staffs’ acceptance and support of implementation activities and willingness to try new things to manage BPSD.
Some participants suggested that having access to a dedicated space and supplies for activities facilitated consistent implementation efforts. Having activities readily available helped engage residents as discussed earlier and supported strengthening staff-resident relationships.
Care Process Changes
Participants discussed making process changes in care delivery to incorporate implementation activities into routine operations. In response to difficulties in getting information passed on to staff about residents and implementation activities, as well as shift to shift blaming for lack of follow-through, some NHs focused on improving processes around staff-staff and leadership communication. One participant stated:
Goal number one, we were in the process, but this put an emphasis on ensuring that all staff had access to information. This has made information more accessible. (3-310)
Important information to communicate among staff included specific information on residents’ behaviors and needs, and individualized approaches. The most common process changes employed to improve communication was the addition of weekly one-on-one meetings with staff and/or weekly team huddles to discuss specific residents experiencing BPSD and adding the research facilitator (as a behavioral expert) to mood and behavior rounds. One NH reported scheduling huddles immediately after weekly care conferences to support consistency. Participants from these homes discussed the importance of creating a non-threatening, constructive social environment where staff were open to new ideas, felt comfortable asking questions about things they did not understand, and provided regular feedback and dialogue about residents.
Some stakeholders described adapting care planning processes to promote implementation of EIT-4-BPSD:
We started a new behavioral care planning process. We meet weekly to take a deeper dive into why behaviors are occurring, identify and eliminate triggers. (2-306)
NHs who made process changes to implement EIT-4-BPSD described moving away from check-box care plans provided by electronic medical records to more customized individual care plans written free hand. For example, one participant described an organization-wide documentation program that included residents’ behaviors, triggers, and interventions in their electronic medical record system where nurses are required documents. They also described changing verb tense of care plans to first person, called “I” care plans. Other participants described creating processes to share individualized care plan information with front-line staff by either creating a resident summary or adding information to existing tools used by direct-care staff. Not all NHs implemented changes in care planning processes; some expressed that their care plans were already person-centered, and changes were unnecessary.
A few participants reported making process changes to improve the quantity and quality of recreational activities offered to residents, and by extension family members. Meaningful activities that were engaging, resident focused [based in resident preferences], and addressed BPSD in place of medications. This included music and memory programs, and gender specific programs. One stakeholder illustrated the importance of meaningful activities:
Cutting down on psychotropics. Increasing activities. We have more resident focused groups now like a men’s group. For the women we had a mother/daughter tea... (2-306)
Staff engagement to provide residents with activities was essential, especially within the activities department and CNA staff. Participants from one NH described making significant changes to the activity department structure; they now hire people with specific skills to implement projects. Another NH started family education nights to facilitate family engagement in interventions to reduce BPSD.
Directly addressing challenges in staff engagement, some NHs created formal processes to engage staff in performance improvement activities around BPSD. For example, one participant described successful changes to behavioral rounds procedures including moving the time and location of meetings to better engage front-line staff and sending a clear invitation to the meeting with times and expectations for participation. Once invited, engaging staff on regular basis with “high energy”, facilitators provided motivation for continued participation.
Maintenance
Maintenance explored the sustainability of the EIT-4-BPSD program as part of the regular routine of the organization (9). Predominantly describing organizational level commitments to continue implementation activities, one distinct category of future plans for implementation emerged. Participants from over half of the NHs described a desire to continue to develop and advance specific organizational goals, continue weekly behavioral meetings, remain on tidbit lists, provide educational in-services on BPSD to staff, and monitor measures of success.