Psycho-educational Approaches in Long-term Care Homes: Direct Care Workers and Managers’ Perspectives Academic research paper on "Economics and business"

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Procedia - Social and Behavioral Sciences 131 (2014) 406 - 410

WCETR 2013

Psycho-Educational Approaches In Long-Term Care Homes: Direct Care Workers And Managers' Perspectives

Ana Barbosa a *, Mike Nolan b, Liliana Sousa c, Daniela Figueiredo d

a PhD researcher, Department of Health Sciences, University of Aveiro, Aveiro, Portugal b Professor, School of Nursing and Midwifery, University of Sheffield, Sheffield, United Kingdom c Professor, Department of Health Sciences, University of Aveiro, Aveiro, Portugal d Senior Lecturer, School of Health Sciences, University of Aveiro, Aveiro, Portugal

Abstract

The majority of the Direct Care Workers (DCWs) in long-term care (LTC) facilities have no formal qualifications or training on dementia and experience high levels of stress and burnout as a result of dementia-related symptoms and behaviours. Psycho-educational (PE) approaches can be effective in supporting DCWs, yet, they are underdeveloped within the context of formal care. Therefore, this study aimed to explore the expectations and concerns of care home managers (service managers and toplevel managers) and DCWs about PE interventions. A qualitative, cross-sectional study was conducted. Individual interviews with 8 managers (75% female; mean age 45.5 ± 10.26) and 8 focus-group interviews with a total of 58 DCWs (female; mean age of 44.72 ± 9.06) of 4 LTC facilities were performed. All interviews were recorded, transcribed and analysed through thematic analysis by 2 independent judges. Managers' main expectations were related to the opportunity to improve DCWs': understanding and attitudes towards dementia; ability to interact with residents; motivation and job satisfaction. DCWs expected to: acquire knowledge and practical skills to deal with dementia; develop their knowledge about resident's biography; enhance their ability to deal with job strain; share experiences and improve group cohesion. Lack of time and support to translate learning into practice and sustain potential benefits over time were anticipated as the main barriers by both elements. There were coincident expectations and concerns among both managers and DCWs. Findings underscore the importance of targeting both DCWs-level and manager-levels perspectives to the planning of a sustainable PE intervention for DCWs.

© 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.Org/licenses/by-nc-nd/3.0/).

Selection and peer-review under responsibility of the Organizing Committee of WCETR 2013.

Keywords: dementia, direct care workers, expectations, long-term care facilities

Corresponding Author: Ana Lmsa Balonas Barbosa. Tel.: +351 234247113 E-mail address: anabarbosa@ua.pt

1877-0428 © 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

Selection and peer-review under responsibility of the Organizing Committee of WCETR 2013. doi:10.1016/j.sbspro.2014.04.138

1. Introduction

Direct care workers (DCWs) provide the majority of daily hands-on care to people with dementia in long-term care (LTC) facilities, therefore they are most likely to influence their quality of life and care [1]. Yet, they have an unquestionable emotionally challenging job [1]. Persistent behaviour and psychological symptoms of dementia (BPSD), as agitation, coupled with a lack of training to handle them, emerge as significant sources of DCWs' stress and burnout [2]. Besides, the lack of teamwork, support and reward from care home managers contribute to overall DCWs' strain [3]. Despite the available evidence suggesting that staff mental well-being can affect the process of caring for people with dementia [4], the provision of emotional support to this workers remains scarce. Psycho-educational (PE) approaches by responding to both educational and emotional needs can be effective in supporting DCWs. PE interventions have been widely used with family carers of people with dementia [5], but are still underdeveloped within the context of formal care. This study sought to explore the expectations and concerns of care home managers (service and top-level managers) and DCWs about PE interventions. By collecting the perception of different grades of staff it is expected to increase knowledge for a better fit of the intervention to the needs of the target population and organizational setting.

2. Methods

2.1. Design

A qualitative cross-sectional study was conducted with DCWs and managers of 4 LTC facilities in the central region of Portugal (Aveiro), between November 2011 and December 2012. Approval to conduct the research was provided by the Health Sciences Research Unit: Nursing (UICISA: E), hosted by the Nursing School of Coimbra, Portugal.

1.2. Recruitment procedures and participants

Four LTC facilities were contacted and the service managers were informed about the project. All facilities agreed to participate. The manager of each facility was asked to identify staff members that maintained direct contact with people with dementia during care provision and were employed for at least 2 months; temporary workers, trainees, DCWs working only on the night shift and other health or social care practitioners (e.g., nurses) were excluded. A meeting with eligible DCWs, service managers and top-level managers was scheduled in order to explain the project and invite them to participate. Potential participants were clarified about the voluntary nature of their participation and anonymity and confidentiality were assured. Written informed consent was obtained from those who accept to participate.

A total of 66 participants were recruited. These included DCWs (n=58) and managers (n=8). DCWs were all female, mainly married (67.2%) and with an average age of 44.72 (±9.06). Nearly half of the participants (46.4%) had the primary and middle school and 41.3% the high school (Table 1). The average length of employment was 9.61 years (±3.72). The majority of the managers were female (n=6) with an average age of 45.5 (±10.26).

1.3. Data collection

Data were collected through eight staff focus-group ranging in size from 5 to 12 DCWs, and eight individual interviews with the managers of each facility. The interviews were held by a trained gerontologist (1st author) at workplace. A semi-structured guide was used, including the following questions: What do you expect from a psycho-educational programme? What barriers or constraints do you anticipate to the development of a PE intervention? Questions were followed by probes and paraphrasing of content to elicit more detail (e.g., 'can you explain further?'). Each interview was recorded and transcribed verbatim. The average length of the focus-group interviews was 43.21±10.08 minutes; individual interviews had an average duration of 35.66±12.98 minutes.

1.4. Data analysis

Both the individual and the focus-group interviews transcripts were analysed using thematic analysis. The

process of creating and testing the categorisation system was gradually refined by two independent judges (1st and 4th authors) as follows: (1) the text was read several times to construct a sense of the text as a whole; (2) a list of preliminary codes was created; (3) the codes were sorted into categories and then integrated into major themes; (4) the categorisation was compared and discussed between the two judges until reach a consensus; (5) a critical feedback was performed by the other authors. Data was managed using qualitative data analysis software - webQDA (University of Aveiro, Portugal).

Table 1. Background characteristics of DCWs

Outcome Direct Care Workers (n=58) N %

Gender

Female 58 100.0

19-28 2 3.4

29-38 14 24.1

39-48 20 34.4

49-58 19 32.7

>59 3 5.1

M (SD) 44.72 9.06

Marital Status

Married 39 67.2

Widowed 3 5.2

Single 4 6.9

Divorced/separated 9 15.5

Other 3 5.2

Education

Primary school 15 25.8

Middle school 12 20.6

High school 24 41.3

College degree 1 1.7

Other 6 10.3

Working time (years)

<1 4 6.8

2-6 10 17.2

7-11 32 55.1

>12 12 20.6

M (SD) 9.61 3.72

Results

Four unifying themes in both groups of respondents were found: knowledge and skills to improve dementia care; work attitudes and psychological wellbeing; group cohesion and barriers to PE interventions. Themes are described with reference to extracts from the data.

3.1. Knowledge and skills to improve quality of dementia care

Most of the managers expected that DCWs could understand the importance of focusing on the person more than on the task. They would like to see DCWs prepared to provide a more individualised care and to encourage residents' involvement during daily routine, in order to maintain their dignity and highest level of functioning:

"My expectation is that they become trained and prepared to deal with residents with dementia (...) obviously it is much easier to grab the spoon and give the soup at once to residents. But this is not beneficial for this kind of residents. They [DCWs] have to grab the spoon and show how the resident should do.and they should be attentive to their reaction. (...) I hope that they could encourage residents' involvement." [Manager, facility 2]

"I want them to improve their daily behavior with the residents (...) the main error is treating every person in the same way. The person is admitted with some limitations and they do nothing to recover them. (...) I want them to acquire competences and to recognize that there is always something that people with dementia can do." [Manager, facility 3]

One manager underlined the importance of DCWs to learn effective ways of communicating with people with

dementia. The need for staff to adapt their communication to the resident, in order to create an enriched environment between both, was emphasized:

"Support for DCWs to have a more accessible language and to understand what the resident wants to express. If they could understand the resident, the relationship between them would be better." [Manager, facility 1]

Managers also noted that guidance during care practice would be important to strengthen DCWs' competences, as programs are often more focused on classroom instruction and less on practical training:

"If they could put into practice what they have learned, first with your support and then by themselves, I think they will effectively change and learn. The new skills will become part of their routine." [Manager, facility 1]

As well, DCWs stressed the importance of acquire new information to be used in daily practice and advice on how to manage residents' behaviors. Participants emphasized that a focus on understanding the residents' personal history would facilitate care delivery. Despite feeling competent and confidence about their actual performance, DCWs noted the importance of being trained by 'professionals with specialist knowledge':

"I hope to learn something new that could help me in my daily practice" [DCW, LTC facility 4] "(...) I would like to know how to control their behavior". [DCW, LTC facility 2]

"We think that is the care we provide is right but there may be other techniques which can help us, and so it would be useful to learn them". [DCW, facility 1]

3.2. Work attitudes and emotional wellbeing

Managers expected that the intervention could enhance DCWs' attitudes towards their work. They would like to see highly motivated and satisfied staff as this could improve their performance and productivity:

"(...) more pleasure, more motivation, more commitment. ..yes more commitment! (...) If they were more motivated, things would be different." [Manager, facility 2]

Instead, DCWs reported the need to be recognized by their emotional demanding job. A few participants would like to have the opportunity to share and vent their emotional concerns in a trustful environment. Others called for practical strategies to handle job stress, as relaxation. Time management skills were also mentioned to be required, as this was thought to alleviate feelings of frustration that emerge from the incapacity to provide a better quality of care:

"We need to talk, to vent what we have been building up." [DCW, facility 1]

"Here, at the facility, we should have someone that we could trust our concerns." [DCW, facility 1]

"We need support for handling stress, for example by relaxing or receiving massages." [DCW, facility 4]

"Help to create time within time. Sometimes we feel so dissatisfied because we can't do more for them." [DCW, facility 4]

3.3. Group cohesion

The need to improve peer-relationships was stressed by all respondents. Managers reported the existence of 'highly competiveness' among DCWs and a 'lack of teamwork'. According to their view, staff should be given appropriate methods to handle interactions assertively in order to improve interpersonal relationships. For DCWs there is lack of trust, union or respect between workers. Participants would like to have a space where they could socialize, share their experiences and raise mutual respect:

"Staff should learn to be more confident with each other" [Manager, facility 1]

"We need a space where we can be together, help each other or even talk about job issues" [DCW, facility 3]

3.4. Barriers to PE interventions

All interviewees noted that time constraints and difficulty in sustaining potential benefits over time were two main barriers to effective PE interventions. Respondents saw managers as a pivotal figure and particularly commented on their ability to change practice. According to DCWs, managers could allow them to have enough time to translate learning into practice. For managers, their role in supervising DCWs post-intervention is fundamental:

"My greatest fear is that everything will work well until you leave, but then things will be lost. I believe we will need to be constantly

supervising them." [Manager, facility 2]

"I think the PE intervention will help us if they [managers] enable us to practice, if they give us time to put into practice what we have learnt." [DCW, facility 1]

Discussion

Managers and DCWs identified a range of expectations and barriers regarding the development of PE interventions for DCWs. Both groups stressed the need for knowledge on dementia, skills to deal BPSD and practical guidance to promote and sustain change. Support to improve DCWs' teamwork, workload and time management has also been mentioned as a key-element to be included on a PE intervention. These results strengthen the need of DCWs to be provided with education as well as with tools for stress and emotional management as this can be critical to promote practice change and performance improvement. Moreover, findings are consistent with the available evidence, which identifies limited time and difficulty in sustaining potential benefits over time as barriers to interventions in LTC facilities [6]. This means that, irrespective of the content of the programme, it is important that managers support and encourage change, by allowing, for example, DCWs to practise and maintain the acquired skills.

The present study underscores the importance of engaging different grades of staff in the design of interventions. Both DCWs-level and manager-levels perspectives are fundamental to plan sustainable PE interventions and tailor them to the culture and particularities of the facilities in which they are to be implemented.

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