Expert Support for Psychosocial Interventions

Care homes play a significant role in dementia care, housing over a third of people with dementia—representing 50-70% of the care home population. Ensuring these facilities provide high-quality, person-centered care is an international priority. Psychosocial interventions are recognized as tools to improve care, but their successful implementation hinges on the capabilities of care home staff. However, a significant challenge arises from the often inadequate preparation of staff for this demanding role, due to factors such as low levels of education, training, literacy, and numeracy among the workforce.

Many trials of psychosocial interventions in care homes lack comprehensive implementation evaluations. Common barriers identified include insufficient staff motivation, attitudes, and confidence; top-down implementation approaches that diminish staff ownership; time constraints, competing priorities, and high staff turnover; limited management support; absence of specific implementation support (supervision, mentorship); staff skepticism regarding the practicality and impact of interventions; and the lack of a 'learning organization' culture. These factors collectively hinder the effective delivery of person-centered care and the successful integration of psychosocial interventions.

Despite anecdotal evidence suggesting the benefit of external expert support in dementia care interventions, limited research has explored this role from the viewpoints of both external experts and care home staff. While some studies have examined either expert or staff experiences separately, a comprehensive understanding of their perspectives and the dynamics of their interactions remains elusive. The current study aims to fill this gap by investigating the role of external expert support in the context of Dementia Care Mapping (DCM) implementation, examining the perceptions and experiences of all involved parties.

Dementia Care Mapping (DCM), while used internationally, has yielded mixed results across various trials. Studies involving researcher-led DCM cycles have demonstrated benefits at the resident level; however, those with care home staff-led cycles have not shown the same positive outcomes. Externally led cycles are uncommon, yet anecdotal evidence supports the feasibility of successful care home implementation of DCM. Significant challenges remain regarding the factors that contribute to successful DCM implementation, with common obstacles including the time demands of training and implementation, high workload and staffing pressures, insufficient mapper preparedness, and a lack of organizational or management support. These challenges underscore the need for a deeper understanding of the role of external support in addressing these issues.

This study employed a multi-methods approach within a process evaluation of a cluster randomized controlled trial (RCT) focusing on Dementia Care Mapping (DCM) implementation. The research design incorporated both qualitative and quantitative data collection methods. Interviews were conducted with six external experts who also completed questionnaires; 17 care home managers; and 25 care home staff members (referred to as 'mappers') responsible for DCM implementation. Data analysis involved descriptive statistics and template analysis for qualitative data. The study was conducted in 50 care homes across three regions of England, with 31 homes randomly assigned to the DCM intervention group. A subset of 18 intervention homes, selected to represent the range of DCM implementation experiences (0-3 cycles), participated in the qualitative process evaluation. The selection was based on the number of completed DCM cycles throughout the 16-month trial period.

The seven expert mappers participating in the trial were recruited from the University of Bradford's network of DCM Trainers and Evaluators. Participants held various levels of DCM training/expertise (Basic User, Advanced User, Evaluator, and Trainer), involving a combination of theoretical and practical training, real-world experience, and rigorous assessments. At the time of the study, DCM Evaluator status was no longer offered within the University's DCM training portfolio. All seven expert mappers were qualified health professionals (nurses, occupational therapists, speech and language therapists) with experience in health and social dementia care services. They possessed substantial experience in DCM, including delivering training courses, conducting mapping cycles, supervising mappers, and coordinating DCM programs. A one-day training session on the trial protocol, processes, and standardized documentation was provided to all experts before commencing their roles.

Care home mappers were identified by home managers in consultation with researchers. A set of criteria, detailed elsewhere, guided the selection process. Key criteria included sufficient English language skills (both written and spoken) for training and report writing; adequate IT skills for report generation; and overall enthusiasm for the role. Mappers also needed to be available and willing to attend a mandatory four-day DCM training course. This standardized selection process aimed to ensure the quality and consistency of the participants involved in the DCM implementation process.

Data collection involved interviews and questionnaires. Eleven researchers, mostly female (8; 73%) with an average age of 24, conducted the interviews, which were audio-recorded and transcribed verbatim. Mapper and manager interviews occurred in private locations within the care homes. Expert mapper interviews were conducted via telephone or in person at the experts' workplaces. Independent researchers, not involved in the DCM intervention, conducted these interviews, focusing on experiences with DCM implementation and external expert support. Expert mappers completed standardized data collection forms following each supported mapping cycle, containing both closed and open-ended questions regarding various aspects of the DCM process, support required, and mapper capability for future cycles. All participants received information sheets and had opportunities to discuss the study before participation.

Seven expert mappers participated, with six providing interview data (three individual, three group). Data collection forms were returned for 28 of 31 intervention homes completing at least one cycle component; three homes didn't complete any components. Interviews were conducted with 17 care home managers and 25 care home mappers (two held both roles). Interview lengths varied: 5-38 minutes (managers/mappers), 31-92 minutes (expert mappers). Expert mappers' contributions included ensuring accurate DCM use, rectifying implementation issues, and improving mapper skills and confidence. However, this support, while appreciated by some, was perceived as overly demanding by others. The expert's contributions were significant; however, their presence wasn't always welcomed, particularly when offering advice on residents they didn't know. Expert mapper data revealed that 64.3% (18 of 28) of homes would benefit from further support on at least one DCM component despite in-person support being unavailable in subsequent cycles. This highlights the need for ongoing support rather than one-time intervention.

Maintaining a balance between providing adequate support and avoiding overreach was a crucial challenge. Experts faced pressure to adhere to trial timelines while fostering positive relationships with mappers. One expert described feeling like a 'jobbing rep,' highlighting the difficulty in balancing support with maintaining positive working relationships. The boundaries of support were sometimes unclear, with experts occasionally involved in facilitating relationships and staff engagement beyond the scope of direct DCM implementation. This blurred line between appropriate support and direct intervention required careful navigation by the experts.

Communication between experts, managers, and mappers presented difficulties. Reliance on phone and email proved inefficient due to staff availability and irregular email access. The experts' extensive experience (many were long-term DCM trainers) also resulted in geographical challenges, requiring long travel days and limiting flexibility. This lack of proximity made last-minute adjustments or flexible support delivery difficult, emphasizing the need for local support. Participants, including both managers and mappers, expressed a strong preference for in-person support versus remote communication methods such as email and video conferencing.

The trial's design limited expert support to the first DCM cycle, preventing proactive, ongoing support, despite concerns identified by the experts. While mappers could access phone/email support from the trial's DCM lead afterwards, this wasn't seen as a sufficient replacement. Data suggest expert predictions of ongoing support needs after one cycle are unreliable. The findings raise questions regarding DCM's suitability as a solely staff-led psychosocial intervention in care homes and suggest that the success of interventions in care homes might depend on wider contextual factors, including the organizational culture and management support. Furthermore, challenges in using computers for report generation and a lack of understanding of person-centered care and DCM application, persisting even with expert support, highlight issues with both the DCM tool itself and the adequacy of the standard DCM training course.

The study's key conclusion emphasizes the critical need for ongoing support from an external expert to ensure the successful implementation of staff-led interventions within care homes. The provision of external expert support for a single cycle proved insufficient to facilitate sustained implementation. While acknowledging the substantial resource implications of long-term support, the researchers highlight the significant risks associated with partial or complete failure of implementation in the absence of such support. This underscores the importance of investing in sustained expert guidance to maximize the effectiveness of interventions aimed at improving the quality of life for individuals with dementia residing in care homes. The cost of ongoing support needs to be weighed against the potential losses incurred from incomplete or unsuccessful intervention implementation.

To optimize resource allocation, the development of tools capable of more accurately identifying areas of concern and predicting the likelihood of sustained independent DCM usage by mappers and care homes is crucial. The study found that initial expert assessments of ongoing support needs were unreliable predictors of future requirements. Therefore, more sophisticated predictive tools could guide the allocation of resources, ensuring that support is appropriately targeted and efficient, avoiding unnecessary expenditure while ensuring the long-term success of the intervention. This could lead to more effective and sustainable implementation of interventions in care homes.

Future research should focus on effectively integrating external support into the design and delivery of dementia care interventions. Investigating methods for assessing and tailoring the level of support provided to individual care homes and mappers based on their specific needs and context is vital. This targeted approach could optimize resource utilization and enhance intervention effectiveness. Further research should also explore the broader contextual factors within care homes and their influence on intervention implementation success. This includes addressing issues such as unsupportive management or negative organizational culture, as these factors can significantly impact the ability of staff to implement and sustain new interventions, even with external support.