Dementia Care

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48 Australian Journal of Dementia Care October/November 2016 Vol 5 No 5
Strategies for changing staff care practices
There are no ‘magic bullets’ when it
comes to changing staff practices to
improve care and outcomes for
people in residential aged care. After an
extensive review of published studies
from around the world that evaluated
interventions designed to change how
staff care for residents, we can report that
staff behaviour change is difficult and
complex. There were many unsuccessful
interventions. However, change is
possible and we were able to identify
elements that contributed to the success
of those interventions that changed
practice.
This article summarises our findings,
including the things that residential aged
care service providers should consider
when contemplating programs requiring
staff to change their behaviour and
practices.
Reviewing the evidence
We conducted a systematic review in
2015. Two members of our research team
went slightly cross-eyed reading the 7572
articles that came up in our search, before
these were culled to 79 eligible papers
reporting on 63 studies.
We excluded articles which focused
only on staff well-being or turnover, or
increasing staff knowledge without
measuring changes in behaviour. We
included only those studies which
measured quantitative outcomes before
and after the intervention. We did not
include studies where researchers
intervened directly with residents.
We grouped studies into clinical
domains. These were: oral health (three
studies); hygiene and infection control
(three studies); nutrition (two studies);
nursing home acquired pneumonia (two
studies); depression (two studies);
appropriate prescribing (seven studies);
reduction of physical restraints (three
studies); management of behavioural and
psychological symptoms of dementia (six
studies); falls reduction and prevention
(11 studies); quality improvement (nine
studies); philosophy of care (10 studies);
and other (five studies).
For each study we recorded which
intervention strategies were used to try to
change staff behaviour. These ranged
from education material for individual
staff, to larger scale organisational
restructures (see box above).
What we learnt
Akey finding was that no single strategy
resulted in a greater likelihood of staff
practice change. In particular, providing
training alone (without support from
other strategies) was not effective.
We found that most studies reported
using more than one type of strategy.
Even so, there was no evidence that
practice change outcomes improved as
the number of strategies increased – there
was no ideal number of components (eg
two versus four).
Rather the important considerations
reflected the features of the targeted staff
behaviours or the work context. It
appears to be easier to change staff
behaviours in specific care tasks (eg oral
care, physical restraints) than to change
global practice (eg introducing person-
centred care philosophy). Many studies
reported barriers relating to staff (eg
turnover, high workload, absenteeism,
attitudes) or organisational factors (eg
lack of funding, resources and logistics).
We also observed an interesting
outcomes asymmetry. Studies showing
change in staff behaviour did not always
result in improved outcomes for residents
(eg improved staff assessment of
depression did not reduce levels of
resident depression). However, studies
that showed improved resident outcomes
also reported changes in staff behaviour.
The explanation for this finding is not
clear and warrants follow up. It could be
related to the way that interventions
targeting staff were developed and
evaluated. For example, studies show
there were better outcomes if they used
an intervention theory, such as Rogers’
diffusion of innovations theory (which
seeks to explain how, why and at what
rate new ideas and technology spread).
Barriers around organisational and
system issues seemed to relate
specifically to implementing the new
practices (eg insufficient funding,
logistical issues and infrastructure
difficulties). Several studies mentioned
barriers and enablers related to resdents’
high-care needs or attitudes of residents
and/or families – these were rarely
targeted as part of the intervention.
Implications for practice change
Aged care service providers
contemplating programs requiring
residential care staff to change behaviour
should consider the following:
Introduce a multifactorial program
rather than training alone – consider
changing policy and procedures, using
reminders, appointing staff champions,
and using quality indicator data in audit
and feedback.
Investigate and address barriers and
enablers for the program – find out from
staff, residents and family what problems
they anticipate with their program (eg
lack of time) and address these.
Use a theory of behaviour change or
implementation – the choice of theory
Mixed methods
The following strategies were identified
in our review of interventions designed
to change staff practices in residential
aged care:
• Educational material: written material or
a DVD/video or online website.
• Training: delivered in person to staff.
• Reminders: for example, postcards,
posters designed to prompt practice.
• Audit and feedback: formal monitoring
of the performance of staff or the
organisation which is fed back to them
(eg antipsychotic prescription rates).
• Mentoring or support: supervision/
consultation/mentoring of staff in teams
or individually to support practice
change.
• Champions: individuals or teams
responsible for driving change within the
site.
• Team meetings: consensus/
multidisciplinary team meetings to
discuss issues relating to the clinical
domain of practice.
• Policy/procedure: a new policy or
procedure introduced into the
organisation (eg reporting tool,
assessment tool, guideline, clinical
decision-making software).
• Organisational restructure: change to
the responsibilities of staff or the way
care is organised.
DCRC SPEC I AL I SSUE : THE B I G P I CTURE I N DEMENT I A RESEARCH
Successfully changing staff practice in aged care homes to improve outcomes for residents is not easy,
but a recent study has identified strategies that can be used. Lee-Fay Low, Jennifer Fletcher,
Belinda Goodenough , Yun-Hee Jeon, Christopher Etherton-Beer , Margaret MacAndrew and
Elizabeth Beattie report