Leading by example: Nursing home staff experiences of what facilitates them to meaningfully engage with residents with advanced dementia.

OBJECTIVES: Meaningful connections promote the quality of life of people living with advanced dementia in nursing homes. However, evidence internationally suggests people living with advanced dementia in nursing homes spend the majority of time alone, with little contact with anyone. Frontline care workers are in powerful positions to meaningfully engage with residents, yet research to date has not focused on their experiences. The aim of this study was to explore the experiences of nursing home staff, specifically, what care workers feel enables them to meaningfully engage with residents living with advanced dementia. METHODS/
DESIGN: Semi-structured interviews were conducted with 21 staff from seven nursing homes. Inductive thematic analysis was used.
RESULTS: Four themes were important for facilitating care workers to meaningfully engage with residents with advanced dementia: support from managers and nurses, support from experienced care workers, a caring culture and an appropriate physical environment.
CONCLUSION: Effective leadership was the key thread that ran throughout. It was evident that meaningfully engaging with residents with advanced dementia was hard, particularly for new or inexperienced care workers. Those with experience (of care work and the residents they cared for), as well as those in formal leadership positions played key roles in facilitating care workers to: perceive it was their role to connect, understand, accept and empathise with residents, understand the importance of getting to know residents' and express their own caring attributes. Future research should focus on empirically testing leadership models that promote meaningful engagement.

INTRODUCTION

It is important that older people with dementia are supported to live well. Meaningful engagement assists this by promoting identity and quality of life. , However, a person's ability to proactively engage diminishes as their dementia progresses, placing them at risk of a diminished quality of life and/or social isolation. Those who are unable to communicate verbally, experience sensory impairment and have limited mobility are most at risk. ,

Almost 500,000 people live in approximately 17,500 care homes in the UK and it is estimated that 70% are living with dementia. , In the UK, different types of care homes (residential and nursing) provide different levels of care. Residential care homes (85% of the total) provide personal care, including to those with mild‐moderate dementia. Residents with advanced dementia, however, who require medical care and depend on registered nurses and care staff for support with all aspects of their daily life are usually cared for in nursing homes (15% of the total) ,

A significant body of international observational research demonstrates residents with advanced dementia spend their days alone with little interaction. Activities are directed towards active or cognitively intact residents. , , ,

Frontline care workers, also known as care assistants, nursing assistants and certified nursing assistants, are in powerful positions to meaningfully engage with residents. Care workers provide more than 90% of direct care to residents in nursing homes, and are one of the few sources of meaningful engagement for residents with advanced dementia.

Care workers caring for people with advanced dementia, however, have reported struggling to understand and interpret communication attempts of those with advanced dementia, which then are unnoticed or unintentionally ignored.

Research around how to enrich the lives of people living with advanced dementia has predominantly focused on the potential of psychosocial interventions, , , , utilising controlled research designs to explore their effectiveness. Additionally, qualitative studies have provided insight into staff's underlying reasons, opinions, and motivations for meaningfully engaging. , Few studies have focused on care workers' day to day work or gained their perspectives on what enables them to meaningfully engage with residents with advanced dementia (Bunn et al., 2018). Indeed, the voice of care workers has been neglected in the discussion of quality of care for people with advanced dementia in nursing homes both in policy and research.

Understanding the “practical wisdom” of care workers and those they work with through accounts of their work experiences and perspectives on engagement is essential for understanding the care delivery process. This is particularly relevant in the wake of the COVID‐19 pandemic, where damage control is needed to overcome the impact of enforced social distancing and visiting restrictions, which left residents confined to their rooms and starved of stimulation for prolonged periods of time.

The aim of this study was to ask nursing home staff what facilitates them to meaningfully engage with people with advanced dementia.

METHODS

We adopted an Interpretivist approach, which considers reality to be socially constructed. Consistent with this, we employed a qualitative method based on semi‐structured interviews, supplemented by informal conversations. The study is reported in accordance with the consolidated criteria for reporting qualitative research guidelines

Ethical issues

The study protocol was reviewed and ethical approval granted by the Humanities, Social and Health Science Research Ethics Panel at the University of Bradford. As the research aim was to identify best practice, there was low risk of distress to participants, however, if poor practice had been uncovered, the researchers would have followed Department of Health guidance on protection of vulnerable adults. Participants' personal details were only linked to anonymised transcripts and field notes via a code. All were held securely in a locked cabinet in a locked room, with personal details held separately. Audio recordings of interviews were downloaded digitally and held securely on password protected computers in accordance with the Data Protection Act.

DATA COLLECTION

Setting

There were two inclusion criteria for nursing homes:

Each needed to provide care for people living with advanced dementia

At least one nursing home needed to provide outstanding care, as indicated in Care Quality Commission (CQC) inspection reports. This was to maximise the likelihood of uncovering best practice. The CQC is the independent regulator for Health and Social care services in England. They ensure Health and Social care services provide safe, effective, responsive and compassionate care by monitoring and inspecting services to make sure they meet key quality standards. Ratings range from outstanding to inadequate care. Inspection reports are published and are available in the public domain.

Purposive sampling was used to ensure nursing homes varied by size (small to large) and setting (urban vs rural). The lead author had previously had a role of bringing together researchers with ‘research ready care homes’ so in keeping with the aim to explore good practice, she was able to approach nursing homes where she had previously observed connections between staff and residents with advanced dementia.

Participant recruitment

Nursing home staff who cared for, or observed care of people living with advanced dementia, were invited to take part via initial information from the nursing home manager. Staff were invited to express their interest by calling the research team who followed up with a full information sheet and a call to answer questions and take oral consent. These explained the nature of the study, including the formal interview and informal conversations, as well as confidentiality and risk. Written informed consent was then obtained from staff on the day of their formal interview between December 2017 and July 2018.

PROCEDURES

We conducted semi‐structured, face‐to‐face qualitative interviews with participants. In‐depth qualitative interviews are a powerful way of gaining insight and interpretation into the social worlds of people and generate rich data. Interviews took place in quiet and private rooms in nursing homes. The interview guide (Supporting Information S1) was flexible. We began by asking broad questions about how and when care workers meaningfully engaged with residents with advanced dementia, along with what facilitated and prevented engagement. We then moved on to focused questions about: who, what, why, where and when meaningful engagement occurred. By asking for specific examples, we were able to gather detail of actual moments of meaningful engagement, rather than generalised or impersonal ideas. All interviews were audio recorded and subsequently transcribed. In addition, the lead researcher spent a prolonged time in the nursing homes informally chatting with staff, including immediately after they had performed or observed personal care to get examples of the times they had connected. These were recorded using field notes. Frequent collaboration between authors occurred to ensure questions and responses pertained to the study's aims and objectives, sufficient progress was being made and any problems discussed.

DATA ANALYSIS

We used inductive thematic analysis. There were five stages (1) familiarising with the data, (2) thematic coding (3) searching for themes (4) reviewing themes and (5) finalising themes. Phase 1 involved becoming familiar with the interviews by reading and re‐reading transcripts and highlighting pertinent statements. All members of the team read and discussed a sample of the transcripts. This allowed us to become sensitised to the richness of the data and its relevance to our research question. It also ensured we developed consensus when thinking about coding. In Phase 2, the lead author generated and attached initial codes to interesting and relevant features of each transcript. An excel spreadsheet was used to track and compare codes. The study team met regularly to consider the codes and discrepancies were resolved as a team. Phase 3 and 4 involved the collation of codes into themes and reviewing the transcripts again to glean further insights relevant to themes (Supporting Information S2).

In Phase 5, final themes were refined, defined, and named, by asking questions of the data. For each theme:

What we meant by the theme (a description of ‘it’)

Who (staff) was involved?

When did it occur?

Where did it occur?

How did it occur?

Authors collaborated to discuss themes and sub‐themes and gain consensus on the final emergent themes Table 1. Findings were fed back to staff who found them relevant and credible.

TABLE 1

Data analysis, phase 5, defining themes

	Themes
	Support from managers and nurses	Support from experienced staff	Caring culture	Ambience of the environment
What	Embedding philosophies of care and giving permission to engage	Accessible and approachable senior workers who perceive it is their role to teach	An environment which promotes relational working and staff well‐being.	Creating calm and peaceful environments
Who	All care workers and nurses	Senior care workers teaching new or inexperienced workers	Residents, family and co‐workers	Residents, family and co‐workers
When	Creating formal opportunities for handovers, meetings. Informally by being hands‐on, open‐door policy, organisation of care	Experiential learning, usually the job, informally as things arise	Every interaction with residents, family and co‐workers	Mealtimes an during personal care.
Where	Throughout the care home	Throughout the care home	Throughout the care home	Residents' rooms and/or social areas
How	Motivated managers, role modelling behaviours, role modelling, shared vision, giving permission, confidence, motivating staff, approachable, visible, teaching strategies, recognition, getting to know residents.	Organisations: Understand the value of experience, organise care so experienced staff have time and space. Experienced staff: Teach how, when, where and why to interact. Getting to know residents, understand dementia.	Positive attitudes towards dementia, expressing caring values. Prioritising relationships between residents and staff, promoting staff well‐being, teamwork, input from the manager and supervisors	Looking for optimal opportunities, organisation of care—systems. Input from manager

Findings

All the nursing homes that were approached agreed to take part (n = 7); all were privately owned. Two were in urban areas, and five in rural areas. Their size ranged from 22 to 70 beds. To put into context, the average size of a UK care home is 20 beds, with only 10% having more than 50 beds. ,

One was rated as outstanding by the CQC, four were rated as good and two required improvement. Twenty‐one nursing home staff participated: two nursing home managers, one nurse/manager, three registered nurses, four senior care workers, eight care workers, two activity coordinators and one kitchen assistant. All were female, and aged 20–61 years old. There was a diverse mix of ethnicity including staff from: black Caribbean, white British, white European and Asian backgrounds. Interviews varied in length from 14 to 82 min. Table 2 illustrates care home and participant demographics.

TABLE 2

Participant and care home demographics

Participant ID	Role	Experience of working with older people with dementia	Years in the home	Ethnicity	Age	Gender	Care home ID	Setting	Size	Rating
S01	Nurse	4 years	6 years	Black Caribbean	28	Female	NH1	Urban	31	Requires improvement
S02	Senior care worker	15 years	12 years	White (British)	36	Female	NH1	Urban	31	Requires improvement
S03	Senior care worker	6 years	3 years	White (British)	30	Female	NH1	Urban	31	Requires improvement
S04	Care worker	1 year	1 year	Asian	24	Female	NH2	Rural	34	Good
S05	Nurse	1 year	1 year	White (European)	28	Female	NH2	Rural	34	Good
S06	Care worker	2 years	2 years	Black Caribbean	31	Female	NH2	Rural	34	Good
S07	Care worker	3 months	3 years	Black Caribbean	39	Female	NH3	Rural	30	Requires improvement
S08	Activities coordinator	25 years	12 years	White (British)	61	Female	NH3	Rural	30	Requires improvement
S09	Care worker	2 years	2 years	White (British)	20	Female	NH3	Rural	30	Requires improvement
S10	Kitchen assistant	14 years	14 years	White (British)	52	Female	NH4	Urban	70	Outstanding
S11	Senior care worker	10 years	4 years	White (British)	34	Female	NH4	Urban	70	Outstanding
S12	Senior care worker	27 years	8 months	White (British)	45	Female	NH4	Urban	70	Outstanding
S13	Nursing home manager	22 years	14 years	White (British)	46	Female	NH04	Urban	70	Outstanding
S14	Care worker	24 years	20 years	White (British)	55	Female	NH05	Rural	63	Good
S15	Activities coordinator	16 years	12 years	White (British)	51	Male	NH05	Rural	63	Good
S16	Care worker	6 years	2 years	White (British)	26	Female	NH05	Rural	63	Good
S17	Care worker	10 years	4 years	White (European)	41	Female	NH06	Rural	69	Good
S18	Care worker	14 years	14 years	White (European)	48	Female	NH06	Rural	69	Good
S19	Nursing home manager	12 years	12 years	White (British)	43	Female	NH06	Rural	69	Good
S20	Nurse	15 years	15 years	White (British)	38	Female	NH07	Rural	22	Good
S21	Nurse manager	24 years	4 years	White (British)	48	Female	NH07	Rural	22	Good

Four key themes were important for facilitating care workers to meaningfully engage with residents with advanced dementia: support from managers and nurses, support from experienced care workers, a caring culture and the ambience of the environment.

Support from managers and nurses

Managers and supervisors facilitated meaningful engagement by endorsing and role modelling a philosophy of care that put residents with advanced dementia at the heart.

All the nurses and managers interviewed articulated their philosophies of care and spoke about enacting these through their everyday behaviours. Indeed manager/nurses indicated they had a shared vision which encouraged meaningful engagement at every opportunity.

They spoke of embedding this in care worker attitudes from the outset:

I am in charge of training new staff, and I make it clear that interaction is important. We have created a scenario‐based training program to help staff understand that. It is supportive and lets them know from the very beginning that is in our missions and values.(S20 Nurse, NH7, rated good)

Staff need to know that they can do that [meaningfully engage] and have the confidence and the experience to interact, so I need to let the team know that it is a good thing to do and that is how we work here and that is how we touch base with people. (S21 Nursing manager, NH6, rated good)

To get the best life and care for the residents, it is almost like staff need to be given permission to know that caring for people with dementia is about interacting. It is about spending time talking, sharing information, sitting, holding hands, being with the person. Knowing that doing that is just as important as getting somebody ready for bed, getting someone up and dressed on a morning. (S13 Nursing home manager, NH4, rated outstanding)

The registered managers and nurses reinforced messages about meaningful engagement by taking an active part in care work. They saw themselves as leading by example mentoring and supporting staff to enact person‐centred care.

I think you have to lead by example and show staff what to do. I mean I recently had a discussion with one of the care workers. I mean he is absolutely kind‐hearted, but he doesn’t say enough to people and so we were talking it through the other day and I was just sort of saying to him: ‘Say everything you’re doing’ I was trying to get across that you have to communicate, it’s our role and it’s everything we do and that aids good team spirit and morale with everybody. You can’t have one person [staff] not communicating.(S21 Nursing manager, NH6, rated good)

Nurses spoke of meaningful engagement with residents with advanced dementia largely relying on non‐verbal communication such as: eye contact, gestures, touch, and body language.

Sometimes they will only move their eyes towards the window, but you know that they’ve recognised what you’re saying on some level. (S20 Nurse, NH7, rated good)

This was echoed by care workers:

A lot of it is body language and facial expressions. They might pull a pained face, a happy face, a go away I am going to scream at you face. You can tell a lot by just looking at someone’s expression. (S17 Care worker, NH6, rated good)

Nursing home staff described using more physical contact than they did with other residents, such as a reassuring pat on the arm and/or holding their hand. Nurses and managers played a key role in modelling this and ensuring care workers understood it:

You know, you see people here, staff, just sitting and holding someone’s hand and you know it’s very simple, it’s very easy but you can tell that it’s all that person wants. Even if it’s only for a minute or two, they just want somebody sitting next to them to literally hold hands and it might be that they are not saying anything, they are not doing anything, they are just looking around like they do, but the person is getting some human contact and the staff member has made the time, in their day to do it. It is just lovely, it is a lovely thing. (S20 Nurse, NH7, rated as good).

One example that made an impact on a care worker involved a night nurse role modelling meaningful engagement:

She [resident] had spoken to me before but it was only ever a couple of words. The night nurse said ‘oh she loves it when you sing’ so I said ‘oh have you heard my singing?’ Then that night, the nurse started to sing and I joined in. She [the resident] was absolutely beaming and laughing with a smile and for me that was everything. (S19 Nurse, NH6, rated good)

When care workers spoke of opportunities for meaningful engagement, they referred to what they had been told by management:

I’ve always been told to try to use mealtimes to interact as you may not get many other opportunities during your shift. (S16 Care worker, NH05, rated good)

Or quoted the aspects of the home's philosophy of care that the managers and nurses had spoken of around person‐centred care:

Yes you have little moments, it’s how you use that time you have with them.(S04 Care worker, NH2, rated good)

Despite knowing it was their role to engage, many care workers talked about the difficulties they had in engaging with residents:

It’s really hard, you try and try and just get nothing…they’re like vacant. (S03 Care worker NH01 requires improvement)

As well as embedding philosophies of care, managers and nurses therefore also gave care workers reassurance to boost their confidence about engaging with residents with advanced dementia:

It is reassurance for the staff half of the time, because they are frightened that if they are not getting a response, that they’re not doing it right and it’s not that they’re not, it is just that the person is that far advanced that they have lost that skill. It is difficult, it is a difficult field to work in. (S21 Nurse, N07, good)

Managers and nurses were also key in imparting the knowledge to encourage care workers to understand, accept and empathise with people with advanced dementia:

I think because residents are usually chatty aren’t they and then when I think you’ve got somebody that is mute and you’re not getting anything back, so some [staff] just stop speaking to the resident and initiating conversation… it’s my job to explain that is it not the case and to persevere. (S20 Nurse, NH7, rated good)

This was reflected in the interviews with care workers:

She said don’t get disheartened, keep trying, tell her everything you are doing…keep going—don’t give up. (S12 Senior care worker, NH4, rated outstanding)

Care workers echoed the person‐centred messages that the nurses and managers had spoken of imparting about belief and persistence:

As long as you know someone’s in there, then you won’t stop trying, however long it takes. That’s the key, keeping going. (S10 Activities coordinator, NH4, rated outstanding)

Some people do not respond to you, but I wouldn’t stop talking. Some people will not actually respond to you at times. (S11 Care worker, NH4, rated outstanding)

Care workers were supported to understand that residents' reactions were subtle:

It is about that ability to adapt and take the person as they are on the day and actually wanting to go back to try again and getting to know them and how they communicate, because everyone is different. We make sure everyone knows that in our team, I rely on them (team) to help convey that. (S13 Nursing home manager, NH4, rated outstanding)

Staff in the care home rated as outstanding, were encouraged to use strategies such as: speaking clearly using short sentences, making eye contact, giving the resident time to respond and paying attention to their reactions to promote meaningful engagement.

Understanding advanced dementia and its impact on residents helped many care workers ‘play it by ear’. These care workers understood that every person was different, every day was different, and every context was different. They took the person as they were in that moment, seized opportunities to connect when they arose, but also moved on and came back later when they were not getting a response.

It [lack of connection] might just be too hard that day or they might just not be bothered. We all have different moods don’t we, they might just not want to that day. (S06 Care worker, NH2, rated good)

Care workers valued the support given by leaders:

It’s nice to have someone to turn to when you’re finding things hard… Gloria always has her door open. She makes me feel calm, and picks me up when I’m down. (S14 Care worker, NH7, rated outstanding)

Support from experienced care workers

In addition to support from managers/nurses, several care workers, particularly inexperienced or care workers new to the care home, highlighted that experienced care workers facilitated them to meaningfully engage with residents with advanced dementia.

Well, I usually just ask to Rose [senior care worker] to help, if it wasn’t for her I wouldn’t have a clue. It’s like, well sometimes you don’t want to disturb the nurses, or feel stupid if I ask a question that I should know. (S06 Care worker. NH2, rated good).

We ask for help from colleagues, they’ve worked here a long, long, time. I’ve only worked here one year, yes so, they help us I guess, I don’t know what I’d do without Nancy, she is my oracle, she’s everyone’s. She’s part of the furniture. (S04 Care worker, NH2, good)

The first quotation here from S06, illustrates that she saw her experienced colleagues as accessible and approachable in comparison with the nurses.

According to the managers/nurses, ‘experience’ was considered essential to be able to meaningfully engage with residents with advanced dementia:

It takes confidence in your ability to be able to sit and do that and juggle other things and that comes with experience. (S13 Nursing home manager, NH4, rated outstanding)

On several occasions registered managers and nurses talked about ensuring experienced care workers knew it was their role to teach and impart knowledge:

Well, I buddy people up who I think will work well and learn from each other. Some of the more experienced ones have heaps of tips and pointers. (S21 Nursing manager, NH7 good)

The more experienced staff lead by example because I am not always around. (S13 Nursing home manager, NH4, rated outstanding)

In doing so, experienced staff were able to teach care workers the importance of paying attention to their own behaviours during interactions. Senior care workers in the outstanding care home went into detail about this, suggesting that approaching residents in a kind, gentle and caring way at a pace that suited the resident resulted in successful engagement:

Sometimes your facial expressions make them think they are doing something wrong. If your facial expression shows somethings not quite right, that can change their whole mood. (S11 Senior care worker, NH4, rated outstanding)

If this did not work to be patient and persevere:

I tell all my staff it’s all about taking your time and not expecting an immediate response and not to give up. Go in gently. So many people just give up and if you just wait a few minutes, you might get a flicker or a glimmer and then you know they’ve understood you. (S12 Senior care worker, NH4, rated outstanding)

However, whilst experienced care workers could be facilitative, there were examples where experienced care workers were not perceived to assist newer or less experienced staff to meaningfully engage:

Sometimes it’s hard, and there is no one to ask, no one to help us so we just do what we think is right. (S09 Care worker, NH3, requires improvement)

When asked who would know how to help she said:

I don’t know, I aren’t in the cliques. You know, some of them have worked here for years but they all just socialise together. (S09 Care worker, NH3, requires improvement)

In some interviews, care workers who had worked in the nursing home a long time, were described to be complacent or ‘palming work off’:

Sometimes I feel she [senior carer] isn’t that bothered, it’s like her heart isn’t in it anymore…she’s always desperate to get off or swap shifts. (S07 Care worker, NH3, requires improvement)

Two care workers in different nursing homes of a similar size, with different ratings of quality, suggested that the manager played a role in preventing complacency. For example, when asked how nursing home staff dealt with these situations the care workers said:

Well the manager sorts it or if she is not there then the next person in charge, it’s the way it is here. (S17 Care worker, NH6, rated good)

Our manager is fantastic, she goes above and beyond and puts everyone’s needs above her own. (S06 Care worker, NH4, rated outstanding)

Caring culture

There were many examples showing that working in a caring culture facilitated meaningful engagement. Managers described a caring culture as one that prioritised relationships between care workers and residents

I mean what we would like to achieve here is not a ‘them and us’ culture…You can bring yourselves closer by sharing a little bit of yourself. I think that does provoke a nice interaction and nice engagement. (S13 Nursing home manager, NH4, rated outstanding)

And promoted staff well‐being:

I want them [staff] to be happy. I see my role as having a competent, skilled, well‐trained, but happy team. If staff come to work enjoying their job they are going to be better at caring, because they want to be here. (S21 Nursing manager, NH7, rated good).

This narrative around a cohesive team also appeared in care workers' interviews:

I love coming to work because I can actually make a difference, I mean…it’s not always hunky dory and it is hard work but working with Mary and the team takes the edge of those hard times. We really get on great here. (S07 Care worker, NH3, requires improvement).

In caring cultures, care workers had the space and permission to get to know residents. They learnt each resident's likes, dislikes, and background, they learnt their communication repertoire and learnt how to recognise communication attempts. This was done over time, by being hands on, and by receiving support from managers and experienced care workers:

Basically, unless you know the client’s right, you would probably say there is no response, but because we have known them for a long time, especially the ones who have been here a long time, you do see little glimmers, little signs in their face. (S15 Activities coordinator, NH5, good)

You need to get to know the person obviously. Figure out how they like to communicate with you and what you need to do to bring out the best in them. It takes time, time and patience. (S18 Care worker, NH6, good)

Managers/nurses described their role in creating a culture that valued relationships between residents with advanced dementia and care workers:

I tell all my staff it is the getting to know residents that is important. I try to make it clear so we are all on the same page. We are not task focused here on [unit]. (S21 Nursing manager, NH7, good)

Care workers reiterated manager's/supervisor's role in creating caring cultures:

It’s [the environment] definitely because of [registered manager], we had a manager before and it wasn’t like this, I could tell you some stories, but now it is so much better and I swear its cos of [registered manager]. (S12 Care worker, NH4, outstanding)

Yeah well, a good manager is the main thing for us, they referee. There are some people who get on better than others. When people are on who don’t like each other, it can cause problems. Our current manager doesn’t take any of it though. She makes sure there is none of that, which is just as well because I don’t have the stomach for it. (S15 Activities coordinator, NH5, good)

Feeling valued by management and colleague's motivated care workers to connect with residents with advanced dementia:

I love it working here everyone is so nice and helpful, it makes you want to come to work and do a good job. (S16 Care worker, NH05, good)

There were examples where despite having a caring culture, care workers did not meaningfully engage. A manager indicated that in these cases care workers did not stay employed in the nursing home for very long:

You know, it doesn’t always work. In the past I’ve tried many times to create a lovely environment where staff can thrive, but sometimes it is just not there in them. (S13 Nursing home manager, NH4, rated outstanding)

A care worker reiterated this:

She doesn’t talk to the residents or even try, it’s in and out, and that’s not what we’re about here. I’ve tried to tell her; the others have tried to tell her… She won’t last long, they never do, Sarah [manager] won’t have it. (S11 Care worker, NH4, rated outstanding)

Ambience of the environment

Calm and peaceful environments were seen as important for facilitating meaningful engagement.

A care worker in a large nursing home, considered to be of ‘good quality’, discussed the impact a busy physical environment had compared with a quiet environment on how residents responded to her:

So, if people are shouting or anything like that then I find there are a couple of people who don’t tend to eat that well and if you compare it to another time when it is really quiet then they eat really well. So it is definitely about the environment as well as your approach to them. (S16 Care worker, NH05, good)

When asked for a specific example she said:

I think everyone was watching a film or something? So it was just a nice peaceful atmosphere which helps. (S16 Care worker, NH05, good)

A nursing home manager who ran a large home of ‘outstanding’ quality expanded on this. She talked in detail about a calm and peaceful environment as important for facilitating connections. When talking about a particular resident with advanced dementia, she suggested the resident's room was optimal for care workers to connect because of a calm and peaceful atmosphere:

It was quiet and it was calm. It is important. I think this is something on [unit for advanced dementia] that we’ve found makes a huge difference, because you really need to concentrate on the person you’re with and you can’t do that if there are all sorts of other things going on. (S13 Nursing home manager, NH4, outstanding)

The manager of this home talked about how they organised care to ensure care workers had the time to spend in the rooms of residents:

Mealtimes are without a doubt the best time to connect, but are also the busiest…so we came up with a system where everybody (not just care workers) gets involved in meal times, then we can create the space and time for those lovely moments. (S13 Nursing home manager, NH4, rated outstanding)

Other managers reiterated this:

We do all the personal care in twos, but we’ll always make sure someone goes back to spend that extra bit of time when they’ve done the basic care needs. The nurse oversees that. (S21 Nursing manager, NH7, rated good).

DISCUSSION

Four themes were identified through interviews with front line nursing home staff as important for promoting meaningful engagement: support from manager/nurse, support from experienced care workers, a caring culture, and ambience of the environment.

Effective leadership appeared to be the key thread that connected these themes. It was evident that meaningfully engaging with residents with advanced dementia could be hard, particularly for new or inexperienced care workers. Those with experience of care work and the residents they cared for, as well as those in formal leadership positions played a key role in facilitating care workers to perceive it was their role to connect; understand, accept, and empathise with residents with advanced dementia; understand the importance of getting to know each resident; and express their own caring attributes.

The relationship‐orientated approaches used by leaders in our study, including prioritisation of relationships between staff and residents and staff with their co‐workers, has been described in earlier studies. Our study extends this evidence base by adding nuanced perspectives about how to create relationships with residents with advanced dementia.

Leadership's importance for improving quality in care homes is well recognised by researchers , , , , regulators and policy makers. , , However, to date this has not been well researched from the perspective of staff who work on the frontline with people with advanced dementia. Thus, while the importance of leadership is not new, we add to the evidence base by offering the perspective of those care workers who enact and experience these issues first‐hand.

The type of leadership described in this study fits with the model of ‘transformational leadership’; ‘a form of leadership intended to motivate and inspire followers to pursue higher‐order goals through the transformation of followers’ attitudes, beliefs, values and behaviours’ (100: p543). Transformational leadership has been linked to person‐centred care theory and is consistent with the leadership style implied by relationship‐centred care. Previous research shows that nursing leadership styles, focussing on people and relationships, such as transformational leadership, are associated with improved job satisfaction for nurses , increased levels of intention to stay in their current positions and better outcomes. ,

There is also a more recent body of literature that focuses on potential benefits of decentralization of traditional hierarchical leadership, in favour of self‐organised teams, who carry collective responsibility and ownership at all layers of organisations. This ‘adaptive leadership’ approach differentiates between adaptive and technical challenges in an organisation. Technical challenges are easily defined and can be solved with the right expertise, skill, or resources. Adaptive challenges are problems for which there are no single solutions; they require innovatory ways of accomplishing care and often require a change in attitudes, values or beliefs. Adaptive challenges are seen as being owned by the person(s) with the challenge and only that person or group can do the necessary adaptive work, thus leadership at different levels is important. Adaptive leadership is perceived to be a mechanism to promote person‐centred and relationship centred care, particularly for people with long‐term conditions. Empowering leadership at different levels has been the focus of many studies. , , , , , Our findings are consonant with this approach as care workers placed a spotlight on the importance of leadership at different levels, from official management and professionally qualified nurses but also experienced colleagues. This could serve as a useful model for implementing our findings.

Our findings also imply that leaders should have a role in initial selection of staff, as there were examples where despite encouragement from leaders, some staff did not engage. Such staff may not possess the caring values that motivate them to connect. The phenomenon of possessing caring qualities has been described in other populations, using different terminology, such as caring attributes and personality traits , , , and has demonstrated a link between caring qualities of nursing home staff and perceived quality of care. This reveals the importance of management assessing whether potential staff are suitable for a caring role, for example, by employing values‐based recruitment methods.

Leadership in nursing home care, is a complex and multidimensional concept which requires further testing in specific contexts. Interventions are needed to test findings generated in this and other studies.

Implications for practice

Small changes in care workers' everyday routines can be implemented immediately at relatively little cost and disruption; for example, emphasising to staff the importance of getting to know residents, learning their communication patterns, and how they like to connect could improve the frequency and meaningfulness of connections. We found that many of these small changes were encouraged and taught by experienced staff. This has significant implications for ensuring workforce stability. Care homes who rely on agency staff and/or who experience high levels of turnover, may struggle to have the personnel in place to pass on practice wisdom and personal knowledge and model roles. Recognition for good work, including monetary incentives, by those in management could be a way to incentivise staff to remain in post.

Implications for research

This exploratory study provides a foundation to build upon. Future studies could be extended in search of statistical rather than analytical generalizability. One direction of future research could be to use the adaptive model of leadership to inform and develop multi‐level leadership strength through which to promote meaningful care for those with advanced dementia. There were some indications in our findings that the nursing home with an outstanding CQC rating had particularly sound leadership at management, professional and senior care workers levels. Future studies could therefore sample CQC nursing home ratings as a proxy for leadership.

Limitations

There are several limitations. Asking nursing home managers to give out study information, then subsequently interviewing participants in their place of work could have led to selection bias or staff feeling obliged to take part. However, given the complexities of the nursing home setting, this was the most effective and efficient way to access staff. Also, while interviews generated rich, in‐depth descriptions of care, they were reliant on staff self‐reports. Observations could have made the study more robust. However, as most of the interactions occurred in residents' bedrooms during personal care, observation would have been intrusive and was deemed not ethically appropriate. Instead, the lead researcher spent a prolonged time in the nursing homes informally chatting with staff, including immediately after they had performed or observed personal care to get examples of the times they had connected. Finally, our sample was limited to those directly involved in delivering or managing care in the homes. Interviewing those not primarily involved in the organisation of day‐to‐day care that is, health care staff, was beyond the scope of this research. However, our sample was reasonably broad, as we conducted the research across seven different nursing homes with staff in different roles.

Conclusion

Meaningfully engaging with residents with advanced dementia is receiving increased attention. This study highlights the importance of leadership at several levels in encouraging care workers to integrate meaningful engagement as part of everyday care. Those with experience of care work and the residents they cared for, as well as those in formal leadership positions played key roles in facilitating care workers to: perceive it was their role to connect, understand, accept and empathise with residents, understand the importance of getting to know residents and express their own caring attributes. Future research should focus on empirically testing leadership‐oriented interventions that promote meaningful engagement.

CONFLICT OF INTEREST

The author declares that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.

Supporting Information S1

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Supporting Information S2

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