As the 65 and older population increases, the incidence of dementia is expected to rise dramatically (Hebert, Weuve, Scherr, & Evans, 2013), resulting in an increase in the prevalence of dementia in individuals who reside in long-term care (LTC) facilities (Seitz, Purandare, & Conn, 2010). Dementia is characterized by memory loss and the deterioration of cognitive functions, which often affect an individual’s ability to carry out activities of daily living (National Collaborating Centre for Mental Health, 2007). Dementia is also often associated with disturbances in mood and anxiety and with challenging behaviors, such as screaming, violence, repetitive questions, intrusive wandering, and sexual disinhibition. These symptoms, commonly known as behavioral and psychological symptoms of dementia (BPSD), are highly prevalent among individuals with dementia (Savva et al., 2009; Wetzels, Zuidema, de Jonghe, Verhey, & Koopmans, 2010) and are a major source of distress to the individual, as well as family members and care staff.
The current default treatment approach to BPSD is psychotropic medication. One half to two thirds of patients with dementia are likely to be prescribed antipsychotic medications (Bird, Jones, & Smithers, 2007; Fossey et al., 2006), despite meta-analyses showing frequent side effects and only modest efficacy (Sink, Holden, & Yaffe, 2005). However, a variety of effective and complementary nonpharmacological psychosocial approaches to the management of BPSD have been evaluated (Cohen-Mansfield et al., 2010; Takeda, Tanaka, Okochi, & Kazui, 2012), with use of such approaches incorporated into care guidelines and recommendations (Howard, Ballard, O’Brien, & Burns, 2001). Such approaches need to be individually tailored, as BPSD vary markedly from one individual with dementia to another and often have idiosyncratic bases (Bird, Llewellyn-Jones, & Korten, 2009). However, individually tailored approaches are likely to be more resource intensive than the use of medications and may place extra demands on care staff, despite the potential reduction in BPSD and the resultant reduction in distress for both residents and care staff. Although training programs have been developed to help staff detect and manage BPSD without relying on medication (Bourgeois, Dijkstra, Burgio, & Allen, 2004; Perry et al., 2008; Sung, Chang, & Abbey, 2008; Zwakhalen, van’t Hof, & Hamers, 2012) and have demonstrated potential to improve resident care and reduce the stress levels of staff, the longer-term effectiveness of such training in managing BPSD depends heavily on the level of staff compliance with learned protocols.
Multiple barriers exist to changing the practices of health care professionals to ensure compliance with newly learned nonpharmacological protocols to manage BPSD. Barriers include a lack of time to implement new protocols (Hart & Morris, 2008; Hutchinson & Johnston, 2004; Parahoo, 2000); limited resources (Hutchinson & Johnston, 2004; Parahoo, 2000); limited access to psychological consultations (Olafsdóttir, Foldevi, & Marcusson, 2001); concerns that the protocol will interfere with patient care and lack of organizational support (Hutchinson & Johnston, 2004; Parahoo, 2000); and a lack of staff knowledge, confidence, and skills (Hart & Morris, 2008; Hutchinson & Johnston, 2004; Richards, Ryan, McCabe, Groom, & Hickie, 2004; Thompson, McCaughan, Cullum, Sheldon, & Raynor, 2005; Upton, 1999).
Research suggests that the use of particular training techniques can improve the compliance of health care staff with mental health protocols (Grimshaw et al., 2001, 2004). Although the most common training method is education, or education in combination with skills training, interactive learning has consistently demonstrated higher levels of behavior change than the passive dissemination of information (Grimshaw et al., 2001; Thomson O’Brien et al., 2001). The interactive approach helps ensure staff have the adequate skills and knowledge prior to implementing new protocols. In addition, research shows that multifaceted programs that address multiple barriers to change, such as lack of organizational support, are more effective than one-dimensional interventions (Grimshaw et al., 2001; Perry et al., 2008; Teri et al., 2010).
Training programs that have used multifaceted and interactive protocols to help staff better manage BPSD among aged care residents with dementia have demonstrated promising outcomes, suggesting that this approach can be effective (Bourgeois et al., 2004; Perry et al., 2008; Sung et al., 2008; Zwakhalen et al., 2012). However, the majority of these studies have not assessed whether compliance with the learned protocols was maintained.
Research has not clearly demonstrated that compliance with protocols learned in staff training programs translates into better outcomes for residents. One study by Zwakhalen et al. (2012) found that after training, staff complied with and regularly administered a pain assessment tool to nursing home residents with dementia. Despite administering the tool, the majority of staff did not address residents’ pain concerns that were identified by the instrument, suggesting that simply training staff to identify the source of BPSD may not be sufficient to motivate them to take actions that will benefit residents. Despite being trained in assessment, staff may not take action to address the problems if they do not feel comfortable or confident in their abilities (Hammond, 2004; Hart & Morris, 2008). To address this issue, regular consultation with an experienced mental health clinician could help staff consolidate their knowledge and skills, while also increasing their comfort level with new protocols (Hutchinson & Johnston, 2004; Parahoo, 2000). This clinical support could facilitate long-term compliance and help attenuate BPSD among residents.
A previously conducted randomized controlled trial (McCabe et al., 2014) assessed the use of a structured clinical protocol designed to help staff in residential care settings better identify the cause of any particular BPSD and implement a tailored intervention. A further research question was whether clinical support was needed in addition to educational and skills training in use of the protocol, and how this support might moderate the outcomes. Using this protocol, staff members were able to systematically assess for causal factors for BPSD and develop interventions for a number of domains, beginning with common medical, physical, and mental illnesses whose presence often manifested as BPSD. For example, if a resident exhibited verbally nonaggressive agitation, such as screaming or cursing, use of the instrument helped staff identify possible underlying medical factors (e.g., pain, urinary tract infection) that contribute to discomfort and agitation, and then appropriate interventions were implemented. If the behavior persisted, an assessment of the distress that the behavior caused others was performed to determine whether it was necessary to address distress as a clinical target in its own right. If further intervention was required, the daily care practices of staff, which can be the most common environmental causes of aggression (Bridges-Parlet, Knopman, & Thompson, 1994), along with the physical environment, were assessed and modified.
The protocol section for each domain included detailed questions and a summary statement. This section was helpful in situations where medical assistance was required, as it provided the treating physician with additional information on which to base prescribing decisions rather than just the information that could be derived from a brief discussion with the RN who was on duty at the time when he or she visited the facility.
The results of the study by Bridges-Parlet et al. (1994) indicated that participation in a brief workshop on BPSD and person-centered care and the use of the structured protocol, together with follow-up clinical support for its use, was associated with more long-term reductions in the challenging behaviors of residents and associated staff response measures than a condition in which staff attended a workshop for use of the protocol but received no clinical support. Results were also superior to a condition in which staff were provided with the workshop on BPSD and person-centered care and follow-up person-centered clinical support, but not the structured protocol. This finding suggested that although multifaceted and interactive training techniques may contribute to improving staff self-efficacy and well-being, more effective long-term improvements in the management of behavioral problems of residents and staff well-being may require the addition of clinical support for use of the protocol.
Although the outcomes of the trial by McCabe et al. (2014) provide evidence of the effectiveness of this protocol and that provision of clinical support is a factor contributing to its effect, the authors of the current study were interested in whether this clinical support translated into greater compliance with the protocol, and whether this compliance was related to subsequent outcomes. To elucidate these points of interest, the current study aimed to investigate whether the addition of clinical support in the aforementioned study improved staff compliance with the structured protocol, and whether this compliance was related to greater long-term reductions in BPSD. Two specific predictions were made. First, it was predicted that care staff receiving training in the use of the structured clinical protocol and clinical support for its use would show higher levels of compliance with the protocol than staff receiving training in the use of the protocol but no clinical support. Second, it was predicted that higher compliance with the protocol would be associated with greater improvements in BPSD and reductions in staff stress at 3- and 6-month follow-up.
Residents. The sample comprised 101 aged-care residents who were recruited as part of a randomized controlled trial of the effectiveness of the structured clinical protocol in helping care staff understand and manage challenging behavior in dementia. Their participation in the study was consented to by their relatives or guardians. This aspect of the study is described in more detail elsewhere (McCabe et al., 2014). The clinical support group included 53 participants (72% women) with a mean age of 84.74 (SD = 6.85 years), and the no clinical support group included 48 participants (71% women) with a mean age of 82.85 (SD = 8.45 years). These participants were drawn from eight facilities, four of which were randomly allocated to each condition. All participants had a diagnosis of dementia and the presence of at least one challenging behavior, defined as “any behavior associated with dementia which causes distress or danger to the person with dementia and/or others” (Bird et al., 2009, p. 74). Examples of these behaviors were physical and verbal aggression, repetitive questioning, wandering and absconding, and refusal of care.
Staff. The primary point of contact at each facility was asked to recruit and obtain consent from staff members from each of the facilities. In the condition that included clinical support, 50 staff (26 personal care assistants [PCAs], 14 RNs, and 10 other professional staff [e.g., lifestyle assistants, diversional therapists]) were initially recruited, of whom 94% were women. The mean age of participants was 45.46 (SD = 12.19 years). In the condition without post-training clinical support, the initial sample of 49 staff consisted of 28 PCAs, 17 nurses, and four other professional staff, of whom 85.7% were women. The mean age of these participants was 44.51 (SD = 13.97 years).
The compliance rating was developed by the research team for the current study and reflected adherence to the protocol. Five levels were developed, with scores ranging from 0 to 4: 0 = nothing completed beyond resident demographics; 1 = only ratings of the frequency and risk of the behavior were completed; 2 = some sections of the assessment were completed, but there was no indication of action; 3 = sections of the assessment were completed, and it was indicated that action was taken as a result; and 4 = the structured clinical protocol was fully used as per instructions, with all necessary sections completed, and there was indication of action and the outcome of this action. In total, 50% of the clinical protocols were examined and rated for compliance by two members (D.H., M.S.) of the research team, with Cohen’s kappas showing an acceptable interrater reliability of 0.85. The remaining protocols were then assessed by a single researcher (D.H.).
Several measures of challenging behavior were used to assess the relationship between compliance with the structured clinical protocol and outcomes. The overall score of the 14-item short-form version of the Cohen-Mansfield Agitation Inventory (CMAI; Cohen-Mansfield, 1986) was used to measure challenging behavior at pre-intervention (Time 1 [T1]), 3 months (Time 2 [T2]), and 6 months postintervention (Time 3 [T3]). The CMAI was completed collaboratively by at least two care staff members from each facility who had concurrent knowledge of the resident; they measured the frequency of behaviors manifested over the previous 2-week period. Responses were recorded on a 7-point Likert scale, ranging from 1 (never) to 7 (several times an hour). Good interrater reliability has previously been reported for this measure (Werner, Cohen-Mansfield, Koroknay, & Braun, 1994). In the current study, internal reliability was acceptable (α = 0.79).
Staff stress associated with each resident’s behavior was measured using the self-report Carer Stress Scale (Bird, Llewellyn-Jones, Smithers, & Korten, 2002). Staff who were familiar with the resident rated how much stress the identified behavior caused them on a 5-point Likert scale, ranging from 1 (no stress at all) to 5 (extremely stressed). Two to three staff members completed this scale at each time point, and the average of these scores was calculated. The average interrater reliability of these ratings across time points was α = 0.66 for ratings made with two staff and α = 0.70 for ratings made with three staff. The disruptiveness of the resident’s behavior on other residents, staff, and visitors was also assessed using the same method on a 5-point Likert scale, ranging from 1 (not disruptive) to 5 (extremely disruptive). Good test–retest reliability has been demonstrated for this disruptiveness measure (Bird et al., 2007). The average interrater reliability of these ratings across time points was α = 0.64 for ratings made with two staff and α = 0.73 for ratings made with three staff. For both measures, where staff attrition occurred, other participating staff members who were familiar with the resident completed the outcome measures.
The study was approved by the ethics committee at the authors’ institution and the research boards of the participating aged-care facilities. Among the recruited residential aged-care facilities in the broader outcome study, eight were relevant to the purposes of the current study (with the remaining facilities assessing outcomes in conditions in which the clinical protocol was not implemented). Four facilities for each of the two conditions (clinical support or no clinical support) received staff training in the use of the structured clinical protocol. Aged-care residents were recruited through consultation with senior staff at each facility, who nominated residents with dementia who displayed the most significant behavioral disruption. The CMAI ratings were conducted by participating staff members familiar with the resident and his or her behavior. Participating nursing staff were assigned to specific residents and were responsible for overseeing the use of the protocol. However, the implementation was a collaborative process among participating staff, whereas additional staff not trained in the use of the protocol also performed specific assessments or interventions as an outcome of its use (i.e., PCAs were asked to modify care practices when working with a particular resident).
In both conditions, a 2-hour training session on the use of the protocol was provided; in the clinical support condition, a 2-hour educational workshop providing an overview of dementia, BPSD, and person-centered care strategies was also provided. Staff members in both conditions were instructed to use the structured clinical protocol with participating residents. In the clinical support condition, a registered psychologist, experienced in working with BPSD, provided support to staff over six biweekly sessions of 2 hours each. These sessions were conducted at regular times every 2 weeks following the completion of the training, in either a one-to-one or group-based format (dependent on staff availability and needs). Although facility management promoted these sessions to care staff, they were not mandatory, but were rather used on an as-needed basis. The clinical support focused on helping staff use and integrate the structured clinical protocol into the care and management of residents who were participating in the study. As such, clinical support involved using the protocol to: (a) systematically identify and discriminate possible causal or maintaining factors of BPSD (e.g., pain, depression, environmental factors [i.e., overstimulation]); (b) provide clarification regarding the related interventions indicated by the protocol (e.g., analgesic agents, counseling, antidepressant agents, changes to the environment); and (c) provide support and problem solving in implementing the protocol and interventions. No such clinical support was provided to the other condition. Outcome measures were collected for all residents and staff at T1, T2, and T3. Following the collection of outcome data, copies of the completed structured clinical protocols were collected, reviewed, and given a compliance rating.
To test the first hypothesis pertaining to differences in mean compliance ratings between the clinical support and no clinical support conditions, an independent t test was performed. As randomization to conditions occurred at the level of aged-care facility, linear mixed models were generated to account for random variation among facilities while testing the second hypothesis of compliance effect on BPSD outcomes. SPSS version 22.0 was used to estimate a series of linear mixed models for each dependent variable (i.e., CMAI score, stress, disruption). Compliance ratings were estimated as a fixed effect. To assess whether clinical support condition or time point was a moderator for associations between compliance ratings and the dependent variables, interaction terms for these variables were also entered as fixed effects. To account for variation in population distributions across facilities, this variable was specified as a random factor. Time was also included as a random factor to account for the correlations between scores across the repeated measures.
An independent t test was conducted on the compliance rating variable to compare scores between the clinical support and no clinical support conditions. The results indicated, as predicted, significantly higher ratings of compliance in the clinical support condition (mean = 2.90, SD = 1.60) compared with the no clinical support condition (mean = 1.02, SD = 1.44), t(100) = 6.22, p < 0.001, d = 1.24.
The Table shows the results of the linear mixed models. The results indicated that compliance was not significantly associated with CMAI score, stress, or disruption as a main effect. Although the effect of compliance rating on the CMAI score marginally failed to reach significance, an interaction effect was noted with condition. In the clinical support condition, higher compliance ratings were associated with significantly higher scores on the CMAI, whereas in the no clinical support condition, the inverse occurred. A significant interaction effect was found between compliance rating and time point for staff stress and perceived disruption outcomes, indicating that higher compliance ratings were significantly associated with higher levels of stress and perceived disruption at T2 but not T3.
Results of Linear Mixed Models on Cohen-Mansfield Agitation Index (CMAI), Stress, and Disruption Scores
The aim of this study was to examine the effect of clinical support on care staff compliance with a structured protocol designed to help staff identify and address common causal factors behind BPSD, rather than simply regarding the behavior as the focus of treatment. An additional aim was to examine the association between compliance and behavioral outcomes for residents and associated staff outcomes.
The results supported the first hypothesis; significantly higher compliance occurred with the structured protocol in the clinical support condition than in the no clinical support condition. Moreover, effect sizes indicated that these differences were large. The current study represents one of the few studies to date to measure the specific effect of clinical support on staff compliance and demonstrates that if staff members are provided with support from a mental health professional, their compliance with protocols is higher. Although difficult to determine from the current data, these compliance effects are likely to be the result of a number of factors related to clinical support, such as encouragement of a proactive approach to using the structured clinical protocol and ongoing support and guidance in implementing the protocol.
The mean compliance rating in the no clinical support condition (1.02 of a possible 4) indicates that in the absence of regular and pragmatic support, compliance levels were extremely low. This finding supports prior evidence that the lack of instrumental support from other personnel (Glacken & Chaney, 2004; Parahoo, 2000) and an absence of mental health consultations (Olafsdóttir et al., 2001) can be key barriers to the effective implementation of new mental health protocols by care staff.
Findings regarding the associations between compliance with the structured clinical protocol and changes in challenging behavior and associated staff measures demonstrate a more complex relationship. Compliance with the protocol did not necessarily predict better outcomes. Higher compliance was not associated with CMAI scores as a main effect, but interaction effects showed that higher compliance related to (a) a higher occurrence of challenging behavior in the clinical support condition and (b) a lower occurrence of challenging behavior in the no clinical support condition. Therefore, in the no clinical support condition, increased compliance appeared to be related to more positive outcomes for residents, as predicted. The finding that compliance and outcomes did not share this same relationship in the condition that received clinical support was contrary to predictions.
Higher compliance was also not significantly related to stress and disruption in general, but it was significantly associated with increased stress and disruption at T2. This increase in stress and disruption may have resulted from the purposeful focus of attention on the identified challenging behavior as a result of using the structured clinical protocol. Higher levels of stress may have also been due to the higher workload in implementing the protocol for limited reduction in BPSD during the timeframe of the study. Although the higher levels of stress cannot be confidently inferred, the lack of association between compliance and these variables at T3 (i.e., when staff members were less likely to be using the structured clinical protocol) lends tentative support to this outcome. Overall, these findings do not support the prediction of generalized associations between higher compliance and reductions in staff stress or their perceptions of the disruptiveness of residents’ behavior.
In summary, as per the main study (McCabe et al., 2014), both the structured protocol and clinical support played active roles because, in combination, they produced sustained improvements in resident behavior and a range of staff measures, including stress. Conditions where staff had no access to the protocol but received training in person-centered care and an equivalent level of clinical support, or training in the use of the protocol but no clinical support, only showed short-term improvements in a much smaller range of variables. However, the results of the current study show that the picture is rather complex, and they bring into question the hypothesized mechanisms of change for the main findings of outcomes of the trial—the structured protocol and support for its implementation was the best method of reducing stress, disruption, and frequency of challenging behavior because the support led to more effective use of the protocol (McCabe et al., 2014).
One possible explanation for the current findings is that training and focused clinical support, together with greater compliance with the structured protocol, may have led staff to have a greater understanding of BPSD and an increased sensitivity to and awareness of particular behaviors. Hypersensitivity to residents’ problems has previously been reported in a study in which staff were trained to recognize and respond to depression and were supported by a “study champion” (McCabe, Karantzas, Mrkic, Mellor, & Davison, 2013). The staff in that study identified a large number of residents as having depression, but according to clinical assessments, these residents were not depressed.
A relatively clear association between compliance and improved CMAI scores was manifested in the no clinical support condition. Care staff in this condition, rather than being motivated by reminders or guidance from support as per the clinical support condition, may have had a more intrinsic and outcome-directed motivation for using the structured clinical protocol; therefore, its use was more strongly related to outcomes for residents. However, although this conclusion is only an assumption, the outcome provides support for an association between increased compliance with the structured clinical protocol and a reduction in the challenging behaviors of residents with dementia.
Given the above findings, care staff experiences of clinical support warrant further investigation. Although the impediments to compliance have been studied previously (Hart & Morris, 2008; Parahoo, 2000), it may be useful to understand more about the motivations for compliance in the context of clinical support, and how staff uptake of new protocols is fostered by this support. The question of why and how this corresponds to subsequent outcomes for those in care is also important (Zwakhalen et al., 2012). However, as the current study’s findings suggest, this relationship is not straightforward.
Although structured protocols such as the one discussed in the current study are designed to systematize and streamline the process of identifying and effectively managing BPSD, they may be viewed as a further burden by staff, and compliance may be impeded by an actual or perceived lack of time (Kolanowski, Fick, Frazer, & Penrod, 2010). Therefore, protocols might be best used as a comprehensive replacement for existing procedures, rather than being introduced as an addition. For care staff in residential care facilities, the implementation of and compliance with these instruments may be difficult without the availability of clinical support. These findings imply that when care staff seek clinical support, which might be facilitated (i.e., encouragement by management or used as professional development time), their compliance with protocols such as this may be improved. Compliance is likely to promote higher fidelity in the use of tools and therefore enhance staff members’ potential to improve outcomes for residents. Given the complexity of BPSD in terms of the various causal and maintaining factors, compliance with systematic protocols of this nature may serve to better orient care staff to relevant targeted interventions, as well as economize on time.
The current study examined the effect of clinical support from a mental health professional on staff compliance with a new structured protocol that helped staff identify treatable causal factors for challenging behaviors and found that it produced significant increases in compliance. The association between compliance and outcomes was mixed, indicating that when no clinical support was provided, compliance was low but was nevertheless related to positive outcomes, namely reduced levels of BPSD. Conversely, when clinical support was provided, compliance was higher, but it was either not associated with outcomes, or outcomes were the opposite of what was expected. These associations may represent confounding factors produced by clinical support that distort a clear compliance/outcomes relationship. However, more research is needed to establish the influence of clinical support on the uptake of BPSD management protocols by staff.
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Results of Linear Mixed Models on Cohen-Mansfield Agitation Index (CMAI), Stress, and Disruption Scores
| Compliance rating
| Compliance rating × condition
| Compliance rating × time point
| Compliance rating
| Compliance rating × condition
| Compliance rating × time point
| Compliance rating
| Compliance rating × condition
| Compliance rating × time point