Many people living with dementia have complex needs which are not always fully understood by staff or properly treated. Quality of care can be compromised by staff turnover, low ratio of staff to residents and poor training provision. For researchers, this raised the question of how staff can be better supported to deliver good care that improves the lives of people with dementia.
A person-centred care approach is widely recognised as the standard for dementia care, but practice varies and very few training programmes available are evidence-based or can demonstrate improving quality of life.
The Improving Wellbeing and Health for People Living with Dementia (WHELD) study sought to address this. It consisted of five-year programme, funded by National Institute for Health Research (NIHR), aiming to develop a standardised approach to delivering evidence-based, person-centred care. The WHELD study was led by University of Exeter Medical School, Oxford Health NHS Foundation Trust and King’s College London.
Creating a change
The WHELD study followed on from the work led by Professor Clive Ballard into reducing the use of anti-psychotic drugs in care homes. Specifically, the project aimed to:
- Improve mental health and quality of life.
- Improve the quality of prescription of antipsychotic drugs.
- Reduce agitation for people with dementia in care homes.
Three systematic reviews were carried out to:
- Identify the existing evidence for effective psychosocial treatments for people with dementia.
- Understand what factors influenced care home staff in using psychological and social interventions.
- Identify training materials which were evidence-based and effective in improving outcomes.
By adapting the most effective approaches at the time, the WHELD study developed a therapist-led training programme for care home staff, aimed at increasing social interaction for residents from two minutes a day to one hour of meaningful engagement per week, combined with a programme of personalised care. This involved simple measures such as talking to residents about their interests and involving them in decisions.
The large-scale randomised controlled trials provided conclusive evidence that care and quality of life improved, and agitation and the use of antipsychotic medication was reduced, with just one hour of social interaction per week. Other elements of the programme included training on recognising and addressing unmet needs, creating opportunities for meaningful engagement, activities, and monitoring and reviewing of medication. These all contributed to the outcomes achieved.
Although WHELD proved successful, the research team wanted to find a more affordable programme with a wider reach. A follow-up study explored how the training could be delivered online with therapist support provided via phone, skype and email.
The Improving Staff Attitudes and Care for People with Dementia e-Learning (tEACH) study, was conducted by the University of Exeter Medical School and King’s College London in partnership with the Social Care Institute for Excellence (SCIE). It involved 280 residents and care staff in 24 care homes over nine months.
Care workers took part in an e-learning programme with key modules based on the WHELD training, with or without Skype supervision. They compared outcomes they began to see with those they experienced from usual care before the training began.
Both e-learning training with and without Skype supervision improved resident wellbeing and staff attitudes to person-centred care. The Skype-supported arm continued to deliver improved resident wellbeing four months after the trial was completed.
Although the study found successful outcomes, some clear challenges emerged, including:
- Managers agreed to provide support and time to allow staff to study, but in practice found this challenging.
- Some homes had technology difficulties (for example, restricted WiFi) to enable staff to study on the premises.
- Universally, staff responded positively to the video content and other scenario-based learning, but some found the written learning more challenging.
The next step for the eWHELD project is to create an optimised, cost-effective, national training offer, which can be rapidly rolled out and meet the needs of the residential care workforce. This will be a ‘blended’ learning offer and is likely to comprise of the following:
- A CPD-accredited 12-module online course, mapped to the relevant topics of the Dementia Care Framework, which can be accessed any time in or away from work.
- A managers’ handbook, together with a collection of resources including films, training materials and other third-party content.
The researchers are suggesting the delivery of eWHELD will involve the care home’s manager attending a local half-day briefing and introduction to the programme. They will be provided with a resource pack which will help them implement the programme, and additional material that can be used to supplement individual study in group sessions.
Each staff member will also be given access to the eLearning course, which will record individual progress. Certificates will be awarded to those who complete the programme. Managers will be supported via Skype and email and regular regional events where they can share experiences and learn from each other.
Subject to funding, design and development, work is expected to start later this year, with first phase roll out in 2020. At the same time, the University of Exeter hopes to implement a large-scale evaluation of the course, as part of funded research it is carrying out with other funding partners.
Over to the experts…
Does this offer a solution to standardised training in dementia care? What might prevent care homes from using this learning method?
It’s a good start
Would any of us disagree with the objective for well-trained care workers to offer person-centred care? I think not. The organisation I chair – Think Local Act Personal – has produced statements of what good care looks like, and the one that comes to mind is the statement, ‘I have considerate support delivered by competent people’.
The WHELD study has helped to reveal the stark gap between the rhetoric and reality of personalisation. Its finding that people with dementia living in a care home can expect only two minutes a day of social interaction is a reminder of the distance we still need to travel to close the gap.
I am encouraged that the evidence-backed training led to some improvements, but the barriers identified by the study must be addressed. I’m not convinced that the shift to a ‘manager led’ approach will be enough to overcome the problems care workers experience such as struggling with written learning or the lack of technology for online learning.
The Secretary of State, Matt Hancock has made technology his second priority, so what slice of this can be directed to small care homes? Similarly, Skills for Care produce resources that may assist and then there is support from the various trade associations.
I’m not convinced that a national training programme will fulfil the potential to spread person-centred care or create a more professionalised care workforce, but it’s a good start. Ultimately, what will make the most positive difference to people’s lives is the attitude and approach of the care home owners and the staff who work in them.
Clenton Farquharson MBE, Chair, Think Local Act Personal
Trained workforce is an investment
As I read this, I remain hopeful that the world has moved on since the research began. Much of the care I witness when visiting NCF members is focused on supporting people living with dementia, and the notion of two minutes’ interaction a day as standard practice feels out of touch – and the target of one hour of social interaction a week seems unambitious.
However, this does not take away from the importance of creating learning and development solutions that will reinforce and strengthen the centrality of person-centred ways of working.
I recognise the challenges that the e-learning programme experienced, and again, hope that some of those core barriers relating to technology are reducing, whilst not disappearing completely.
The model suggested around train-the-trainer will appeal to some homes, but as with all training, the final version of the programme must consider and recognise the cost to homes of staff time, both to deliver and attend the session.
I am slightly concerned that the refreshed programme might be focusing on a ‘workaround’ to the barriers identified, rather than seeking to challenge them. We do both our workforce and those we support a disservice if we aren’t clear that quality training and a quality, trained workforce is an investment that society must make.
It’s only through prioritising and centrally funding workforce development, based on programmes like this, that we can ensure staff can deliver the care everyone living with dementia should receive – and, importantly, where, as with WHELD, there is an evidence base to demonstrate that staff trained in this way can fundamentally improve outcomes.
Vic Rayner, Executive Director, National Care Forum
Already shown real promise
Dementia affects 70% of people living in care homes, so it is vital staff have the right training to provide good quality dementia care. We know that care home staff want the opportunity for dementia training and that training is crucial in order to provide the individualised care which can have a significant impact on the wellbeing of people living with dementia.
We need a sustainable and well-funded approach to providing training for our workforce. Alzheimer’s Society supported the early stages of the world-leading WHELD programme, which includes an online training programme for care home staff based on person-centred care, and a range of non-drug approaches.
This programme has already shown real promise in supporting staff to improve the wellbeing of residents. We need training like WHELD to help staff develop the specialist skills and roles required for delivering high-quality dementia care. This would ensure that staff feel more capable and confident in delivering complex care for people with dementia, as well as delivering other benefits such as reducing staff turnover.
Alzheimer’s Society is committed to improving dementia care through research, and campaigning for evidence-based dementia training to be made more accessible. But without sufficient and sustainable Government investment in social care, to cover the costs of training and to allow protected learning time for staff, there won’t be enough money to deliver the specialist care people with dementia need. We look forward to seeing further research to understand the true benefits of online training that the WHELD team have now developed, both for people living with dementia and for care home staff.
Fiona Carragher, Chief Policy and Research Officer, Alzheimer’s Society
Aligns with NICE principles
Providing care and support for dementia patients can be very complex, with variation in the quality of care provided. The NICE guideline aims to improve this by providing evidence-based recommendations for best practice.
The NICE guideline highlights the importance of properly training staff so they are able to provide dementia care that is of high quality and meets the needs of people with dementia. Part of this focus is on person-centred support, where people with dementia are involved in every decision about the care they receive. It also calls on health and social care professionals to develop a support plan. It is recommended they do this by involving the person, their family or carers.
The WHELD study aligns with these principles by providing an accessible training programme for care home workers with the aim of increasing social interaction with care home residents with dementia, combined with a programme of personalised care. With an ageing population more people are living with dementia, so we need to work together to ensure staff have the correct training to support those that are affected.
Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social Care, NICE
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