Background
Aim
Methods
Study design
Research team
Setting and participant selection
Ethics
Data collection
Data analysis
Trustworthiness
Results
Participants’ characteristics
Nursing home (#) | Function in the nursing home | Age (years) | Work experience in nursing (years) | Work experience in the current position (years) | Work experience in the current nursing home (years) | Qualification in addition to basic nursing training: further training (position-specific or dementia-specific) |
---|---|---|---|---|---|---|
1 | Nursing home manager | 55 | 29 | 8 | 10 | Nurse manager education, Higher Education for Health Care Professions Grade I, Trainer with a Swiss Federal Vocational Diploma |
1 | Nursing expert | 41 | 22 | 6 | 10 | Graduated in Nursing Science, university course in «Organisational Ethics», Master of Science in «Nursing Management» |
2 | Nursing expert | 53 | 33 | 15 | 10 | Master of Advanced Studies in «Gerontological Nursing» |
2 | Nursing home manager | 49 | 28 | 11 | 11 | Certificate in «Management in Health Care Systems» |
3 | Nursing expert | 58 | 36 | 2.5 | 2.5 | Certificate of Advanced Studies in «Dementia and Way of Life» |
3 | Nursing home manager | 45 | 25 | 10 | 0.3 | Certificate of Advanced Studies (3 programs) |
4 | Nursing expert | 59 | 18 | 11 | 7 | Course in Validation |
4 | Nursing home manager | 40 | 19 | 5 | 4 | “Postgraduate course «Team Management and Head of Department», Certificate of Advanced Studies in «Gerontological Care», Pain Management” |
5 | Nursing expert | 43 | 20 | 12 | 7 | Master of Science in Nursing, Trainer with a Swiss Federal Vocational Diploma, Validation Basis, Grade I and II, Aggression Management |
5 | Nursing home manager | 55 | 38 | 29 | 1 | Management training for Nurse Managers, Leadership Specialist with a Swiss Federal Vocational Diploma; Quality Management, various professional trainings in the field of dementia |
6 | Nursing home manager | 50 | 30 | 23 | 20 | “Master of Advanced Studies in «Management of Health Care Institutions», Nurse Expert Higher Education for Health Care Professions Grade II, Validation “ |
6 | Nursing expert | 60 | 40 | 20 | 20 | Master of Advanced Studies in «Mental Health», Trainer with a Swiss Federal Vocational Diploma, Certificate of Advanced Studies in «Gerontological Psychiatry» |
Nursing home (#) | Nursing home residents (n) | Residents living in a specialised ward for people with dementia (n) | Specialised wards for people with dementia (n) |
---|---|---|---|
1 | 245 | 41 | 3 |
2 | 223 | 18 | 2 |
3 | 147 | 44 | 3 |
4 | 72 | 48 | 2 |
5 | 131 | 24 | 1 |
6 | 300 | 90 | 4 |
Themes
A common attitude and cohesion within the organization | |
Commitment on several levels | |
A needs-oriented implementation | |
The effect and the public perception of the intervention | |
A structured and guided implementation process | |
Supporting knowledge and competencies | |
Resources for implementing the intervention |
A common attitude and cohesion within the organization
To ensure a collective development, it is necessary to support cohesion and a common attitude. All persons involved should regularly enter into a dialogue with one another and cultivate positive relationships. Therefore, it is required to openly address conflicts and to jointly elaborate projects. This also contributes to team development and facilitates a common attitude in the team as an important prerequisite for successful implementation.«We need common values, visions and strategies. It should be clear that we all work for a common cause and everybody has a role» (nursing home 6, nurse manager, section 53)
In case of too many issues, priorities are not clear, an overview is missing, and issues lose attention at an early stage. This impairs a sustainable implementation.«It is better to focus on one issue and to say: We are going to implement this. We are ready to provide resources. We are going to pursue this in the long run. We really want to live that in everyday life. And we are going to evaluate it. Thinking in long terms … I believe that this is more helpful because people learn something. They have a sense of achievement and they enjoy working together on an issue that has finally become familiar to them» (nursing home 2, nursing management, section 12)
Commitment on several levels
Accordingly, it is essential that the nurses involved understand the intervention. In case of doubts, it is required to address their reservations and to actively strengthen the motivation of every nurse, for example by offering the possibility of personal development or by taking over responsibility within the project. If nurses are not involved, this can result in oppositional behavior and in doubts preventing successful implementation. Conversely, nurses with an open-minded attitude towards innovation approve the project with enthusiasm and contribute to successful implementation.«I believe that the success stands or falls with the enthusiasm of the nurses. It is necessary that they really understand what it is all about. And that they are motivated to put it into practice. That’s very demanding» (nursing home 4, nursing expert, section 29)
Apart from nurses working in direct contact with residents, support from persons in leadership positions is crucial as well. This concerns members of the executive management, nursing managers and ward managers. Their approval is a major precondition for starting the project, for receiving necessary resources, for ensuring the liability and seriousness of the project, as well as for sustainable implementation.Furthermore, not only professionals but also persons with dementia and their relatives should approve the intervention. Particularly, relatives might have a supportive role since it is often not possible to inform the person with dementia about the intervention in a way she/he fully understands. In addition, people with dementia probably might not be able to clearly express consent or refutation. In this case, relatives can contribute to assess how far an intervention conforms to the will of the person with dementia.«Persons with dementia are quite sensitive on the emotional level. They immediately feel whether the nurse is fully committed or not. The nurse should be convinced that she is doing the right thing. Then she helps the person with dementia to feel safe» (nursing home 4, nursing expert, section 55)
A needs-oriented implementation
There are different options for adjusting an intervention to the current situation of a person with dementia. On the one hand, temporal modifications (i.e. duration of the intervention) are possible. On the other hand, individual adaptations (specifically tailored to the person with dementia) may be helpful.«The status of a person with dementia is very volatile. Sometimes mental stability changes within seconds. Or they show different moods on the same day. That’s extremely challenging. It‛s difficult to choose the right time. You can‛t say: Today I‛m going to do this and that. You always have to adapt it to the current situation. You can‛t strictly follow your plan» (nursing home 4, nursing expert, section 93)
The implementation threatens to fail if professionals do not recognize the needs of the person with dementia or if they ignore these needs. It is essential to consider the stage of disease. Dementia is associated with progressing and/or fluctuating physical, emotional and cognitive burden of disease, depending on the stage.«It is essential that the person is ready as well. Especially in the context of Basal Stimulation. And particularly when you work with aroma essences. Naturally, this is very individual. You have to adapt it to the situation. That’s crucial» (nursing home 4, nursing expert, section 17)
Therefore, situational peculiarities are highly important. To perform an intervention according to the needs of the person with dementia, health professionals have to evaluate the current situation and to initiate necessary adjustments. This requires the competence to assess current requirements of persons with dementia. Furthermore, there is also a need for readiness to plan nurse-led intervention autonomously, to implement them in a reflective way and to adapt them according to situational demands.«[Adaptations to the situation ]are necessary for all people. But for persons with dementia adaptations are particularly important. Otherwise, they probably respond very rejecting» (nursing home 5, nursing management, section 55)
The effect and the public perception of the intervention
Particularly with regard to complex interventions in the field of dementia care, an effect is not immediately visible. This may be challenging for the persons involved. High frustration tolerance is required.«It is important to experience the effect and to see it. I somehow experience these moments with the resident. Or the resident flourishes. She feels better or sleeps better. Then it‛s necessary to communicate this. And then I believe that it‛s easy to get the team on board very soon» (nursing home 3, nursing manager, section 73)
Furthermore, it is supportive if the intervention has not only a positive effect on persons with dementia but also on nurses and their work. The intervention may facilitate nursing procedures due to reduced resistance on the part of residents. It may also improve communication with persons with dementia.«If the issue doesn’t work, try it again! Perhaps for the eleventh time … You realize this with issues like validation. Many attend the course for three or five days. They learn a technique or the technique as such is already difficult. And then they are extremely frustrated because they can’t connect it with everyday practice, with their own evaluation of the stage. And in the end, they can’t understand it, they have questions» (nursing home 1, nursing expert, section 59).
A structured and guided implementation process
If a structured approach and the involvement of others are missing, this poses a barrier to implementation. A lack of forward planning may lead to deception and frustration. Therefore, starting with a pilot project seems to make sense, particularly in the case of more comprehensive projects. A pilot project allows to timely recognize difficulties concerning implementation. Participants mentioned that liability is necessary as soon as the project is implemented on a larger scale. Liability becomes evident, for example, in a project agreement, in anchoring the intervention into the organizational structure and in the evaluation of project aims. In case of success, it is necessary to celebrate and to communicate what the team has achieved.«There is a high need for communication in our teams. We have to announce that soon there will be something new and that we want to achieve a certain aim. We probably have to define the aims with the team leader. It’s important to decide what we want to achieve in which period of time. And we have to arrange certain things. Arrangements are necessary to proceed in a structured way» (nursing home 2, nursing expert, section 30).
«At the beginning, you have to practice again and again. Until it really works. And someday it is self-evident, without saying. This is the case in two of our units. There’s no need to discuss anymore. Something that was very hard at the beginning is now just normal. I’s routine» (nursing home 4; director, section 63)
Supporting knowledge and competencies
According to the participants, competency also comprises an open-minded attitude on the part of nurses. Due to this fundamental attitude, the implementation of certain interventions proves to be much easier. As an example, the participants mentioned Basal Stimulation requiring a high level of motivation to concentrate on a person, as well as empathy and low fear of contact.«It’s necessary that nurses have developed the ability of crosslinked thinking … In this respect, our nurses are worth their weight in gold. In two 'segregated living' units, we have nurses with a long history of continuing education. For them, it is possible to link the new issue with the disease and its different types. Due to previous knowledge and basic knowledge, many things are much easier» (nursing home 4, director, section 30)
To maintain knowledge and competencies in an organization, team stability and a low turnover rate are required. In case of high fluctuation, there is a risk of losing knowledge. In this case, the issue is not further developed any more. As a result, rebuilding knowledge is very time-consuming. Team stability and low turnover are a precondition for preserving knowledge. This also enhances the quality of relationships among nurses resulting in intensified, more open-minded exchange. Nurses giving each other feedback and exchanging their knowledge may have a positive impact on the intervention.«These issues should not lose our attention. There is a regular exchange in our standard groups. At least six times a year, regularly, until things tend to turn into a routine» (nursing home 4, director, section 61)
«This works wonderfully on one of my units. Because they also give each other feedback. Positive and constructive feedback. Naturally, this is only possible when the team is holding the strings together» (nursing home 1, nursing manager, section 34)
Resources for implementing the intervention
Optimized staffing and sufficient temporal resources are needed. However, it becomes obvious that nursing homes fundamentally affected by staff shortage cannot operate without additional resources. Otherwise, there is not sufficient time for nurses to implement the intervention.«If you want to implement such concepts, staffing level is a big issue. The team needs certain resources. Whenever you implement something, you should dedicate enough time and attention to this project» (nursing home 5, nursing manager, section 18).
From the participants’ point of view, costs for infrastructure or for training pose a major challenge for implementing interventions. Not every organization can fulfill infrastructural demands associated with a project. This results in additional demands and costs. The participants mentioned technical needs, a lack of room capacities as well as access to nursing databases. Satisfying technical equipment is not always ensured in nursing homes. Room capacities often are insufficient for training or information events. Particularly, a separate room for implementing an intervention is necessary. To change work processes associated with the implementation, training is necessary. This relates to nurses, teams or individual persons. They all need training in order to prepare the intervention and to perform it sucessfully.«No matter how excellent the project is – if I have not enough staff or staff is always reduced, it‛s not effective. It‛s an additional strain on personnel. As much as they try to, they cannot implement it. […] And that’s the key problem […] Staff is necessary. Ideally, I would like to have more staff also in the field of long-term care. But in this area, the need is not yet recognized as urgent» (nursing home 4, director, section 47)