Supporting general hospital staff to provide dementia sensitive care. A realist evaluation.
Background: There are an increasing number of interventions to improve hospital care for patients with dementia. Evidence for their impact on staff actions and patient outcomes is, however, limited and context dependent. Objective: To explain the factors that support hospital staff to provide dementia sensitive care and with what outcomes for patients with dementia. Design: A realist evaluation using a two-site case study approach. Setting: Two hospital trusts in the East of England. Site 1 had a ward for patients with dementia that would address their medical and mental health needs. Site 2 used a team of healthcare assistants, who had support from dementia specialist nurses, to work with patients with dementia across the hospital. Participants: Hospital staff who had a responsibility for inpatients with dementia (healthcare assistants, nurses, medical staff, allied healthcare professionals and support staff) (n=36), patients with dementia (n=28), and family carers of patients with dementia (n=2). Methods: A three stage realist evaluation: 1) building the programme theory of what works and when; 2) testing the programme theory through empirical data (80 hours non-participant observation, 42 interviews, 28 patient medical notes, 27 neuropsychiatric inventory, and documentary review); 3) synthesis and verification of findings with key stakeholders. Findings: The programme theory comprised six interconnected context-mechanism-outcome configurations: 1) knowledge and authority to respond to an unmet need; 2) role relevant training and opportunities for reflection; 3) clinical experts and senior staff promoting practices that are patient-focused; 4) engaging with opportunities to spend time with patients; 5) risk management as an opportunity for person-centred care; 6) valuing dementia care as skilled work. Effective interactions reduced patient distress and supported patient orientation. Training and allocation of staff time were of themselves insufficient to ensure dementia care was prioritised and valued as skilled work. Staff concerns about the consequences of adverse incidents and work pressures on the ward, even with support, took precedence and influenced the quality of their interactions with patients with dementia. A key finding linked to staff retention and developing capacity in the workforce to provide expert dementia care was that despite extra training and organisational endorsement, nursing staff did not regard dementia care as skilled nursing work. Conclusions: There is increased awareness and organisational commitment to dementia-friendly healthcare in general hospitals. However, in addition to training and adapting the environment to the patient, further work is needed to make explicit the specialist skills required for effective dementia care.