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Table 3 Contextual aspects influencing implementation and outcomes of the care concept

From: Mechanisms of impact and contextual aspects of a dementia special care unit in long-term care: a process evaluation

Context aspects [32] Topic and its short description Influence on implementation and/or outcomes of the care concept Quotes or/and extracts from observation protocols
1. (Target) Population Persons with severe physical impairments and/or severe dementia live in nursing homes
Living at home even with (more) severe physical and cognitive impairments is possible due to increased care competence of formal and informal caregivers
Leads to later admissions to nursing homes and changes in resident characteristics
Increased need for support in physical care needs leaves less time to implement the promotion of activities and social interaction “That is what I believe is the problem, that the residents simply come to us with high physical care needs, that we can no longer promote the resources as it is stated in the care concept. In addition, of course we have enough staff for the way this concept should be, but as it looks now, we do not have it anymore and therefore team members are simply and constantly, massively overloaded and frustrated.” (EI3_89)
2. (Target)Population Constant behaviour changes possible
Persons with dementia unpredictably change their behaviour and reactions to interventions, persons or situations
Nurses must be able to manage changing situations at any given moment and therefore all nurses need to have the appropriate skills and knowledge
High need for a stable team competence and early, intensive training of new team members, if this is not achieved implementation of interventions focusing on residents is at risk “With dementia, I will say one thing is that there is no common thread. That is the real tension.” (EI2_63)
“When I come in the morning, I never know - yesterday it was great, and today nothing works. You always have to adjust and make the best of it.” (IG_GI2_ 75)
3. (Target)Population Family members as advocates
As persons with dementia experience difficulty fully recalling their biography and comprehensively assessing situations, family members take on the role of advocates
Need for intensified cooperation with family members, as they have essential information for residents’ care and on the other hand need information to be able to act as advocates, affects implementation of the care concept “My experience is that if we take the relatives on board right from the start and we are very open in what we say and do [...], I actually have the relatives very much on board, they help out, they deal with the biographical work of their own dad, mum or whatever. In addition, that leads them to truly deal with them. You see that. They simply visit longer, inform themselves about their family member, what happened, how is he or she?” (IG_EI1_33)
4. Cultural – attitude of the target population Intolerance of residents towards behaviour that does not meet social conventions:
Residents without, with mild or moderate dementia address behaviour that does not meet social conventions in a punitive manner
Intolerance of socially unsuitable behaviour by persons with dementia influences the outcomes of the care concept of belonging to a social community Note at 10:40 a.m.: R14 goes to the next table and drinks from the glass of another resident, whereupon R8 shouts: “Are you stupid? This is not your glass.” […]
Note at 10:55 a.m.: R8 sits down on an armchair that is not his, another resident starts to nudge him with a stick until R8 gets up and leaves grumbling and grumpy. (B3_p. 5)
5. Cultural - belief of the managers and practitioners Empathy as a must-have in the care for persons with dementia:
For the delivery of interventions focusing on residents, empathy is believed to be essential
Empathy is regarded as a characteristic that is difficult to train
Conscious recruitment of new team members difficult because of structurally small number of nursing staff on job search and may jeopardise the implementation “When we hire someone new, the most important thing for me is that he or she deals empathically with the residents. We look at this by letting them spend two days on the SCU. The staff then gives me feedback on whether he or she fits into the team. I pay less attention to formalities - everything else can be learned in trainings.” (EI6_34)
6. Organisational Transformational, consistently acting leaders shaping the organisational culture and understanding of nursing
Charismatic leaders convinced of their approach to care were seen to inspire nurses and to empower them to act in the same way
Common, person-centred attitude in interaction with each other influences the work climate and care practices
Changes in leaders and personnel may lead to changes in the informal organisational culture and thereby may influence the implementation of the care concept
Expression of common person-centred attitude and conformity:
“We try to determine, what resident like. We look at the biography, where were the interests thus far, talk to the relatives, what they did at home until the end, but you are not allowed to forget that people change. If she was knitting for 40 years, then she often does not want to know anything about knitting anymore. ‘I have knitted long enough, yes, I do not like it anymore - I want to do something new.’ Yes, so people with dementia not only want to do the same old things.” (EI1_18)
“Exactly, and our experience is that relatives say in regard to the biography “Yes, they have always loved having children around” and so on, then we ask them, and they can’t stand it. People change, especially with dementia.” (EI3_6)
Example of conformity:
N4: “If you’re nervous, it is over.”
N6: “If you’re having a bad day.”
N4: “You’re already lost.”
N5: “Because they know that [yes], they pick that up right away. Then, your whole day is gone” (laughs).
N4: “They feel that. [Yeah, right]. Sensors they have. Sensors, they already have good ones. Whenever something is...”
N6: “So the feeling.” [IG_GI2_161–166]
7. Financial Limited time resources in nursing care:
Time resources are limited and are particularly scarce during holiday periods and periods of high sickness absence
Limited time resources influence the implementation of the interventions focusing on residents
Limited time resources sometimes collide with the developed understanding of nursing resulting in a prioritisation of tasks in favour for physical needs and frustration of nurses
“The time you need, you should have; it is very important that you can take your time. Good care needs time.” (GI1_7)
“Five things are going on at the same time. The bell rings, someone shouts, the ward round comes... In addition, then you cannot arrange anything with the residents with dementia. You cannot say to them, ‘Stay here for five minutes, I will be right back.’ They do not know what five minutes is. You have to act immediately.” [VG_EI6_87]