PROJECT REPORT STAFF AS CHANGE AGENTS IN THE MANAGEMENT OF DEPRESSION AGED CARE SETTINGS AND BEHAVIOURAL PROBLEMS ASSOCIATED WITH DEMENTIA IN

Transcription

1 STAFF AS CHANGE AGENTS IN THE MANAGEMENT OF DEPRESSION AND BEHAVIOURAL PROBLEMS ASSOCIATED WITH DEMENTIA IN AGED CARE SETTINGS PROJECT REPORT CHIEF INVESTIGATORS: PROF. MARITA MCCABE PROF. DAVID MELLOR DR. TANYA DAVISON DR. GERY KARANTZAS PROF. KATHRYN VON TREUER RESEARCH PROFESSIONALS: MS ANASTASIA KONIS MS RACHEL HASELDEN MS JERETINE TAN MS KELLY KARANTZAS PROF. DANIEL O CONNOR Funded by A study conducted in conjunction with BlueCross Community and Residential Services, Royal Freemasons Ltd, Aged Care Services Australia Group, Gold Age Aged Care, Allity, Sapphire Care, Bupacare, McKenzie Aged Care Group, Medical and Aged Care Group, The Alliance Care Services Group and Belvedere Aged Care residential facilities Agents: Final Report

2 Table of Contents Executive Summary... 3 Project Need... 4 Project Aims... 4 Overview of Research Design and Methodology... 5 Measurement Tool used in Data Collection... 6 Results... 8 Conclusions References Staff as Change Agents: Final Report

3 Executive Summary The prevalence and under-treatment of clinical depression and behavioural and psychological symptoms of dementia (BPSD) within the aged care sector is concerning. However, training programs designed to improve the detection and management of depression and BPSD in aged care residents have been largely ineffective. The aim of this research project was to conduct a Randomised Controlled Trial (RCT) to evaluate a training program designed to assist management and non-management aged care facility staff in working with residents with depression and/or BPSD, with a focus on organisational factors as well as developing the knowledge, skills and self-efficacy of staff dealing with these issues. The RCT was implemented across 21 aged care facilities (divided into three conditions). The first condition received the training program (Staff as Change Agents Enhancing and Sustaining Mental Health in Aged Care), the second condition received the training program and clinical support, and the third condition acted as a waitlist control by undertaking care as usual. Pre-, post-, 6-month and 12-month follow-up measures of staff and residents were collected. The results suggested that staff in the training condition experienced significant and sustained improvements in knowledge and confidence/self-efficacy in working with residents with depression and dementia, while also reporting lower carer strain. Staff in the training condition also reported a significant improvement in various organisational factors including, workplace trust, cohesion and support. Finally, staff in the training program reported improvements in the mental health referral process in their facility and changes regarding to whom referrals were made. The findings speak to the importance of developing the skills of aged care staff in working with residents experiencing depression and BPSD, while also building the organisational capacities of aged care staff and facilities to sustain changes in practice. 3 Staff as Change Agents: Final Report

4 Project Need Mental health disorders are common in aged care settings. A recent review of the literature reported that almost one third of aged care residents have depressive symptoms while 10% meet criteria for a current diagnosis of Major Depressive Disorder (MDD). 1 However, our research has demonstrated that MDD is typically detected and treated in less than half of these cases. 2 In addition, more than half of the aged care population is estimated to have dementia, which is associated with behavioural and psychological symptoms of dementia (BPSD) (such as agitation, verbal and physical aggression, sleep disturbance, and wandering) in an average of 78% of cases. 1 Research has demonstrated that these disturbances are not well managed by staff in the aged care sector, even after they have received specialised training. 3 While numerous interventions have been trialled to address the deficits in the care of aged care residents with depression and BPSD, the field has failed to demonstrate consistent, cost-effective and sustainable outcomes. The absence of empirically supported evidence for effective interventions for this setting is of concern, given the ageing of the population and the resultant increased numbers of people with depression and dementia requiring residential care. Rigorous trials of novel approaches are urgently required to improve the management of vulnerable older adults with high-prevalence mental health disorders. Project Aims This project aimed to build on our previous work by targeting a core barrier to the provision of appropriate mental health care in the aged care system that is often ignored by the sector: ineffective organisational leadership and culture. Research by our team and others has confirmed that these organisational barriers are a major impediment to the implementation of strategies to better manage both depression and BPSD among older adults in care. 3,4 Despite this, research has yet to address organisational barriers in a systematic way. 5 The current project was designed to address this gap, by implementing and evaluating a strategy that we have used in other health care settings. This strategy applies a transformational training approach to the aged care sector as a means of improving the management of both depression and BPSD. The training program is titled Mental Health Care through Transformational Change (MHCTC). In particular, the present study aimed to evaluate a four-session transformational training program directed at managerial and non-managerial aged care staff using a randomised controlled trial design. It was expected that this program would be superior to a care as usual control condition in terms of: Organisational climate factors such as staff trust, cohesion, communication and supportive workplace relations; Staff knowledge and skills in the provision of mental health care; Referral processes for residents experiencing depression or BPSD. The study also aimed to determine whether additional clinical support is required to sustain the above outcomes over 12 months. It was expected that supplementing the transformational training program with clinical support from a mental health nurse specialist may lead to greater benefits than the same program without clinical support. 4 Staff as Change Agents: Final Report

5 Overview of Research Design and Methodology Our research project involved two stages. The first stage involved the development of our MHCTC program. The development of this four session program was based on evidence from our previously established training programs, our previous findings in relation to organisational barriers in aged care, and our current programs using transformational training in other settings. The program aimed to train organisational and clinical leaders, RNs and PCAs to better detect and manage depression and BPSD, while also providing training in how to improve workplace climate and effective leadership in mental health practices. The content of the four 2-hour sessions of this training program was drawn from our previous training programs for depression and BPSD. Each of these sessions is outlined in Table 1 below: Table 1. An outline of the session content of the MHCTC program. Session 1. Involved training staff in the use of a simple checklist screen for depression as well as how to administer the Cornell Scale for Depression in Dementia. 6 Strategies on how to talk with older people about their depression symptoms, as well as how to recognise masked depression in older people was also addressed. A protocol was introduced for screening, referral, and monitoring of depressive symptoms. The session also included the introduction of a workplace climate framework 48 to increase staff awareness of workplace issues that are associated with barriers to practice change within the organisation. Session 2. Involved assisting staff to recognise the range of behavioural and psychological symptoms of dementia (BPSD), as well as the possible causes of these problems. Staff were trained in the structured BPSD diagnostic tool that we have developed that specifically allows staff to track through possible causes of these symptoms, determine the most probable causes, and implement appropriate strategies to address these symptoms. In addition to this training, specific mechanisms to overcoming the barriers raised in the previous training session were examined. The development of implementation strategies as a way of addressing these barriers was explored in small groups through structured activities. Session 3. Involved the provision of transformational training in how best to enhance the organisational climate in terms of supportive relations, trust, cohesion, and communication across multiple levels of the organisation. It focused specifically on how senior staff can develop the capacities of aged care staff in co-operating and communicating around the recognition and management of depression and BPSD. Session 4. Conducted four weeks after session 3, took the form of a workshop in which staff identified key issues regarding challenges that lead to resistance to change in the detection and management of depression and BPSD. Solutions to these barriers were generated using transformational training principles and the organisational climate framework that underpinned the training provided to staff in sessions 1 to 3. 5 Staff as Change Agents: Final Report

6 The second stage involved conducting a Randomised Controlled Trial (RCT) of the training program across 21 aged care facilities of our industry partners. The RCT comprised of three conditions. We outline these conditions in Table 2 below. Table 2. A description of the three conditions of the Randomised Controlled Trial (RCT). Condition 1 (MHCTC Program). The first condition comprised the implementation of our training program outlined above in seven facilities, specifically targeting senior clinical and organisational leaders as well as senior RNs and Personal Care Assistants (PCAs). Condition 2 (MHCTC Program plus clinical support). The second condition comprised the implementation of our training program to another seven facilities, and also provided clinical support to staff in these facilities to assist them with the roll out of the strategy to better recognise and manage depression and BPSD within the new organisational system. Clinical support was provided by an appropriately trained mental health nurse specialist who was situated within each facility for approximately one day per week for a six month period. Condition 3 (Waitlist control care as usual). The third condition comprised of six facilities that provided care as usual and were allocated as the waitlist control group. These facilities were provided with the option to undertake the training program after the data collection for the RCT was finalised. Participants Aged Care Staff: A total of 252 staff participated in the study which included 42 senior staff (i.e., 2 facility managers and/or RNs from each of the 21 facilities) and 42 PCAs (i.e., 2 PCAs from each of the 21 facilities) assigned to the control condition and two training conditions. Aged Care Residents: A total of 378 residents were recruited to participate in the study. Across each of the 21 facilities, 9 residents with dementia who present with BPSD were selected through consultation with facility staff. Similarly, 9 residents with undetected and untreated depression were recruited across all 21 facilities. Depressed residents were identified through examination of resident files and existing documentation collected for every Australian resident (known as the Aged Care Funding Instrument [ACFI]), which includes a depression screening instrument the Cornell Scale for Depression in Dementia. 6 Participants were identified through selecting those with an ACFI Cornell Scale score above 8, with no indication of a diagnosis or treatment for depression indicated in their resident file or medical records. Current depressive status was confirmed by a clinical interview conducted by researchers, using the Cornell Scale. Informed consent to examine resident documentation at the facility and collect outcome data was obtained from the residents themselves, or if they were unable to provide consent, from their family or guardian. Measurement Tool used in Data Collection All of the measurement instruments used to assess staff and residents were completed at various assessment phases prior and after staff participated in the MHCTC program. Below we outline the measurement instruments related to staff and resident outcomes. 6 Staff as Change Agents: Final Report

7 Staff outcomes Staff completed measures at the 21 residential facilities at pre-intervention, post-intervention, 6- month and 12 month follow-up (or equivalent time for the control group). The specific measures used are briefly described in Table 3. Table 3. Description of staff measures. Staff knowledge of depression and BPSD. Measured using an expanded version of the Knowledge of Late Life Depression Scale - Revised, developed by our team with a sample of 320 care staff in our previous study. 7 This 10-item scale includes three subscales that tap into Symptoms of Depression, Myths about Depression (, and Facts of Depression. Subscales can be aggregated to form an overall score for knowledge in depression. All items are rated on a four-point scale ranging from 1 (strongly disagree) to 4 (strongly agree). Staff confidence/self-efficacy in caring for residents with depression and dementia. Measured using two measures the expanded version of the Self-Efficacy in Working with Dementia Scale, developed in our previous study 8 and the Confidence in Working with Depressed Older People Scale. 8 The Self-Efficacy in Working with Dementia Scale six items that are rated on a five-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Items responses are averaged to provide a total score, with higher scores indicating greater self-efficacy in working with dementia. The Confidence in Working with Depressed Older People Scale includes three subscales related to recognising/detecting depression in residents, listening/asking a resident about depression, and communicating to senior staff about a resident with depression. Subscales can be summed to form an overall score for confidence in working with depression. All items are rated on a four-point scale ranging from 1 (not at all confident) to 4 (very confident). Staff strain in caring for residents with dementia. Measured using the Strains in Dementia Care Scale. 9 The SDCS contains 27 items that measure the severity of strain across five subscales: frustrated empathy (7 items), difficulty in understanding residents (7 items), balancing competing needs (5 items), balancing emotional involvement with residents (4 items), and perceived lack of appreciation from others (4 items). Items are rated from 1 (none/hardly any) to 4 (high stress) and are averaged to derive a total score, with higher scores indicating greater carer strain. Organisational climate. Various subscales of the Psychological Climate Questionnaire. 10 were used to tap into supportive relations, trust, and cohesion. Each subscale consisted of five items rated on a five-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores on each subscale reflect a higher endorsement of the given organizational climate factor. The organisational climate variable of communication was assessed with the 15-item Interpersonal Communication Competence Scale-Short Form (ICCS-SF). 11 Perceptions of changes in mental health referral process. Measured by four items designed specifically for this study tapping into: (1) whether staff perceived that changes were made to the referral process; and (2) whether these changes led to positive mental health outcomes for residents. Items are rated from 1 (strongly disagree) to 7 (strongly agree). Scores across items are averaged with higher scores indicating improvements to the mental health referral process. 7 Staff as Change Agents: Final Report

8 Resident outcomes Resident outcomes were measured by examining mental health processes in terms of the specialist services and personnel to which residents were referred for either depression or BPSD. The specific measures and process for assessment is outlined in Table 4. Table 4. Description of resident measures. Depression and BPSD referral rates to primary and specialist health services were recorded at the 6- month and 12-month follow-up assessments post intervention. Collection of this information at these time frames provided an opportunity for staff to implement changes in procedure that would impact on mental health referral processes. Participating staff were asked to keep records of all such referrals through an information referral sheet where staff noted if a referral was made and to which specialist service or personnel. This information was validated by an examination of files on a bi-monthly basis from the 6-month to 12- month follow-up assessments post implementation of the MHCTC program. Results A series of repeated measures analyses and cross-tabulations were conducted to determine if staff and resident measures of interest differed between the training condition(s) and waitlist control condition. These results are presented clustered by outcomes of interest for the study. These outcomes of interest were: (1) organisational factors, (2) staff knowledge and efficacy in working with residents with depression and dementia, (3) changes in referral rates. The results for each of these outcomes of interest are framed as a series of questions, accompanied by a summary of the findings that addresses each question. It is important to note that while analyses involved the comparison of three conditions (training program, training program plus clinical support, and waitlist control); the findings presented below compare the training program to the waitlist control condition. The reason for this is that no significant differences were found between the training program plus clinical support condition compared to training alone and waitlist control. Specifically, the results of the training program plus clinical support condition fell in between those of the training alone condition and the waitlist control. That is, while the clinical support condition demonstrated some improvement over no training (i.e., the waitlist control condition), the effects were not significantly different, nor did the outcomes exceed the training program alone condition. It appears that the provision of training alone was a powerful factor in shaping the skills and abilities of staff and change processes in aged care facilities. Additional clinical support did not enhance outcomes. It may be the case that staff taking part in the training develop a comprehensive set of skills and abilities that can lead to sustainable change without the need for further help and support. This finding has important practical and financial implications for the sustainability of such programs. In particular, it appears that once training is conducted, the learnings from the program can be sustained without the need to provide further adjunct assistance to staff. 8 Staff as Change Agents: Final Report

9 Did the training program improve organisational factors over time? Yes. The training program was found to improve organisational climate across three of the four organisational factors targeted in the program. As shown in Figure 1, staff in the training program compared to the waitlist control, reported significant improvements in cohesion (F[1,127] = 4.74, p <.05) and increased support (F[1,127] = 3.94, p <.05) from team members over time. Furthermore, staff in non-managerial roles compared to staff in management positions experienced significant increases in workplace trust (F[1,127] = 5.68, p <.05) for those who took part in the training program relative to staff in the waitlist control (see panel f). Panels a through d of Figure 1 illustrate that staff in the training program experienced a rapid increase in cohesion and support that were sustained over time compared to staff in the waitlist control condition. Panel c of Figure demonstrates that non-managerial employees who took part in the training saw a consistent increase in support from staff compared to managerial employees in the training condition. Managerial staff who took part in the training program demonstrated little increase in trust (see panel e). This is largely a result of managerial staff reporting between moderate to high levels of trust before commencing the training program. No significant differences were found in the communication skills of staff assigned to either the training program or waitlist control. Figure 1. Change over time in organisational climate factors for staff in the training program versus waitlist control (a) (b) 9 Staff as Change Agents: Final Report

10 (c) (d) (e) (f) Did the training program lead to staff improvements in working with residents experiencing depression and dementia? Yes. The training program was found to improve staff s confidence and efficacy in working with residents experiencing depression and dementia. Staff also reported reduced strain in caring for residents with dementia. As shown in Figure 2, staff in the training condition compared to the waitlist control, demonstrated a significant increase in confidence in dealing with depression in residents (F[1, 127] = 9.95, p <.01) and greater self-efficacy when providing care to residents with dementia (F[1, 127] = 3.65, p <.05). Staff in the training condition (relative to the control condition) also reported significant reductions in carer strain over time in working with residents with depression (F[1, 127] = 6.65, p <.05). However, no significant differences were found in relation to knowledge of depression (F [1, 127] = 2.47, p >.05). As illustrated in panels a and b of Figure 2, staff in the training program demonstrated significant increases confidence working with depression and self-efficacy working with dementia in residents, and then maintenance these gains for the next 12 months. In relation to staff experiencing 10 Staff as Change Agents: Final Report

11 carer strain in working with dementia residents, panel c of Figure 1 illustrates that staff in the training program demonstrated a significant decrease between pre-intervention and post intervention, and then sustained this decrease over the 12-month follow-up. Figure 2. Change over time in confidence in depression, self-efficacy and strain in dementia care for staff in the training program versus waitlist control (a) (b) (c) Did the training program lead to changes in the referral process by staff? Yes. Staff in the training program rated significantly greater improvements in the mental health referral process of residents than staff in the waitlist control. As illustrated in Figure 3, staff in the training program reported more improvements in the staff referral process at 6 month follow-up compared to staff in the waitlist control (F[1,76] = 3.98, p <.05). Furthermore, staff in the training program reported the maintenance of improvements in the referral process at 12 month follow-up. Figure 3. Changes in staff referral process. 11 Staff as Change Agents: Final Report

12 Did the training program result in changes in the personnel to whom a resident was referred? Yes. Staff in the training program made significantly more residents referrals for depression and BPSD to specialist staff compared to waitlist control staff. As shown in the top portion of Table 5, training program staff, compared to the waitlist control, made significantly more referrals regarding resident s depression to DBMAS at both 6-month and 12-month follow-up, and made more referrals to specialist personnel, colleagues and other services at 6-month follow-up (chi-square likelihood ratios ( 2 > 3.15, p <.05). Likewise, for BPSD resident referrals (see Table 5, lower portion), the training program staff made significant more referrals, compared to the waitlist control at 6-month follow-up DBMAS and specialist staff, and at 12-month follow-up to APATT and other colleagues and services ( 2 > 3.23, p <.05). 12 Staff as Change Agents: Final Report

13 Table 5. Significant differences in referrals for depression and BPSD (training program vs waitlist control) Depression 6-month follow-up Refer to DBMAS 12-month follow-up Refer to DBMAS No Yes Total No Yes Total Condition Training Condition Training Control Control Total Total Refer to specialist Refer to another person/service No Yes Total No Yes Total Condition Training Condition Training Control Control Total Total BPSD 6-month follow-up 12-month follow-up Refer to DBMAS Total Refer to APATT Total No Yes No Yes Condition Training Condition Training Control Control Total Total Refer to specialist Total Refer to another person/service No Yes No Yes Condition Training Condition Training Total Control Control Total Total Staff as Change Agents: Final Report

14 Conclusions Organisational barriers clearly limit the effective translation of skills into the routine care practices of staff to address depression and BPSD among residents in aged care facilities. This project implemented and evaluated a training program (using an RCT design) that upskilled staff in knowledge and abilities regarding depression and BPSD and addressed the organisational barriers to mental health care. It was expected that the training program (compared to a waitlist control), would result in improvements to: (1) Organisational climate factors such as staff trust, cohesion, communication and supportive workplace relations; (2) staff knowledge and skills in the provision of mental health care; and (3) referral processes for residents experiencing depression and/or BPSD. The study also aimed to determine whether additional clinical support was required to sustain the above outcomes over 12 months. It was expected that supplementing the training program with clinical support from a mental health nurse specialist may lead to greater benefits than the same program without clinical support. The findings of the project found that the training program resulted in significant and sustained improvements (for at least 6 months, if not 12 months) across all outcome areas targeted by the program. However, contrary to expectations, the addition of clinical support did not further enhance the outcomes of the training program. Therefore, providing staff with the training program appears to be enough of an intervention to develop the skills and abilities of staff, and to also lead to changes in the procedures and processes implemented by aged care facilities for residents with depression and/or BPSD. As already noted in this report, it may be that by staff taking part in the training develops, within staff, a comprehensive set of skills and abilities that can lead to sustainable change without the need for further help and support. Thus, once training is implemented, the lessons learnt from the program appear to be sustained without additional clinical support. This project is consistent with the national research priority goal of ageing well, ageing productively, and responds to the problem of depression and BPSD in our ageing population through the development of better strategies to address the mental health problems of older people. The significance of this project goes beyond the level of individuals and facilities to the broader community. The outcomes from this study provide evidence that can be used strategically by aged care organisations to inform policy and practice for improved quality of care of older people with depression and BPSD more generally. 14 Staff as Change Agents: Final Report

15 References 1. Seitz D, Purandare N, Conn D. Prevalence of psychiatric disorders among older adults in longterm care homes: a systematic review. Int Psychogeriatr. 2010;22: Davison TE, McCabe MP, Mellor D, Ski C, George K, Moore KA. The prevalence and recognition of major depression among low-level aged care residents with and without cognitive impairment. Aging & Ment Health. 2007;11: McCabe MP, Davison TE, George K. Effectiveness of staff training programs for behavioral problems among older people with dementia. Aging & Ment Health. 2007;11: Cohen-Mansfield J, Werner P, Culpepper WJ, Barkley D. Evaluation of an inservice training program on dementia and wandering. J Gerontol Nurs. 1997;23: Richards DA, Lovell K, Gilbody S, Gask L, Torgerson D, Barkham M, et al. Collaborative care for depression in UK primary care: A randomized controlled trial. Psychol Med. 2008;38: Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in Dementia. Biol Psychiatry. 1988;23: Karantzas GC, Davison TE, McCabe MP, Mellor D, Beaton P. Measuring carers knowledge of depression in aged care settings: The Knowledge of Late Life Depression Scale. J Affect Disord. In press McCabe MP, Davison T, Mellor D, George K, Moore K, Ski C. Depression among older people with cognitive impairment: Prevalence and detection. Int J Geriatr Psychiatry. 2006;21: Edberg AK et al. Strain in nursing care of people with dementia: Nurses experience in Australia, Sweden and United Kingdom. Aging and Mental Health, 2008; 12: Koys DJ, DeCotiis TA. Inductive measures of psychological climate. Hum Relat. 1991;44: DeSanctics M, Karantzas GC. The psychometric properties of the Communication Competence Scale- Short Form. 2012; Unpublished manuscript. 15 Staff as Change Agents: Final Report