Many care homes are struggling to implement a tool designed to help them better meet the needs of people with dementia. New research suggests that care home managers need to be supported, trained and engaged when such tools are introduced into care homes.
The tool, called Dementia Care Mapping (DCM), aims to improve practices in care homes for people living with dementia. The programme asks staff to put themselves in the place of residents, through watching and assessing residents’ experiences. The observations are fed back to the staff team who work together to develop action plans to improve care.
A previous study found that DCM did not lead to improvements in homes. This study explored why. It found that implementation is patchy and vulnerable to issues such as staff and manager turnover, their confidence or skills to lead changes in practice, and inadequate staffing and funds.
The researchers suggest that how well managers understand, value and engage with DCM has a key influence, as does their leadership style.
What’s the issue?
Many people with dementia, particularly those with more complex needs, live in care homes. Care homes often use DCM to improve the quality of care offered to residents with dementia.
To implement DCM, two members of care home staff (the ‘mappers’) are trained to use the tool. They brief other staff about the tool and then sit in the lounge or other public areas to see what daily life is like for residents. They note what residents are doing, how they are feeling and the actions that make residents happy or cause them distress. After coding and analysing their observations, the mappers write a report and feed this back to the team. Improvements are suggested by the staff team, put in place, and the cycle is repeated a few months later.
Earlier studies outside of the UK found that DCM had mixed results across care homes. Where DCM was led by the researchers, there were some benefits for residents and staff. However, where DCM was led by care home staff, no benefits were found and there were problems implementing the tool.
The current study was part of a UK trial which asked trained staff in 31 care homes to complete three cycles of DCM. The first was supported by an external expert provided by the research team. Compared to 19 homes not using DCM, this trial found no benefits in terms of reduced resident agitation, neuropsychiatric symptoms such as depression, use of anti-psychotic drugs, use of healthcare resources or improvements in quality of life. Implementation of DCM was variable.
This study explored the barriers and facilitators in introducing a complex tool like DCM, including the influence of care home managers. It looked at the actions and attitudes of managers themselves, but also the circumstances that enabled managers to support DCM.
Researchers interviewed 48 care home staff (managers and staff trained to use DCM) who were implementing DCM at a range of different-sized care homes in different locations across England. They found that managers played many crucial roles in supporting implementation.
Analysis of the programme identified five themes:
- Managers' support for the intervention was essential. One DCM expert provided by the research team to support implementation of DCM said about a care home that only carried out one cycle: “She [the manager] never attended anything. She never supported, as far as I could see, the mapper.”
- Managers’ understanding of DCM and its potential benefits was variable. Responses ranged from: “It’s a brilliant tool, and just gives you the time to look and focus on what is going on in your home” to: “I didn’t realise how long things would take and how much effort it would take.”
- The choice of staff trained to lead DCM influenced the outcome. One DCM expert said: “Some managers were really clear [on their choice of mappers]. ‘Yep, those two are good communicators, good agents of change, they’ll be good to lead this.’ For other managers it was completely random.”
- Management stability was a challenge with a change of manager in two in five care homes during the 16-month study period. These changes often undermined implementation: “The study was interrupted, the staff that were doing the mapping… left the company, so when I already arrive here [as a new manager], they were not here and I never had any contact with the mapping,” said a manager of a care home that did not complete any DCM cycles.
- Managers' engagement and leadership depended on how well they valued DCM. In homes with higher levels of implementation, managers had the influence to involve the whole team. One expert said, ‘They had plenty of un-rostered time… so they could prioritise it.”
Why is this important?
The study suggests ways to tackle the difficulties in improving care in care homes.
Implementing tools such as DCM in care homes can be challenging and it relies on the support of managers. Management style is rarely studied in the social care sector, yet this study found that managers in homes that had most success with DCM played many crucial supportive roles.
For example, some protected staff time to implement DCM, assisted less confident staff, and engaged staff across the home in DCM and the associated changes in practice.
Managers’ leadership skills and understanding of DCM affected their ability to provide the necessary support. A change in manager often undermined implementation and the researchers suggest it may not be feasible for care homes to introduce such interventions when there is managerial instability.
The findings suggest that managers and staff may require greater support to implement interventions such as DCM. Greater, ongoing support from external experts may also help.
The findings should have direct impact on the delivery of DCM in care homes: they showed that managers need better support, such as a clear understanding of what DCM involves, and extra funds to pay for dedicated staff time. DCM was more likely to be successfully implemented with support from researchers or external experts. They said this was needed on an ongoing basis, not just during the first cycle.
These findings have implications for research on other interventions in care homes. Managers need to be actively engaged from the outset of a research study. The high turnover of managers means intervention research should include strategies to engage and support new managers, and to ensure ongoing engagement from existing senior staff.
You may be interested to read
The full study: Kelley R, and others. The influence of care home managers on the implementation of a complex intervention: findings from the process evaluation of a randomised controlled trial of dementia care mapping. BMC Geriatrics. 2020;20:303
The wider trial findings: Surr C, and others. Effectiveness of Dementia Care Mapping™ to reduce agitation in care home residents with dementia: an open-cohort cluster randomised controlled trial. Aging & Mental Health. doi: 10.1080/13607863.2020.1745144
A summary of DCM implementation: Griffiths A, and others. Barriers and facilitators to implementing dementia care mapping in care homes: results from the DCM™ EPIC trial process evaluation. BMC Geriatrics. 2019;19
The role of external experts: Surr CA, and others. Exploring the role of external experts in supporting staff to implement psychosocial interventions in care home settings: results from the process evaluation of a randomized controlled trial. BMC Health Services Research. 2019;19:790
How well DCM was implemented in the trial: Surr C, and others. The Implementation of Dementia Care Mapping in a Randomized Controlled Trial in Long-Term Care: Results of a Process Evaluation. American Journal of Alzheimer’s Disease & Other Dementias. 2019;34:390-398
Funding: This research was supported by the NIHR Health Technology Assessment Programme.
Conflicts of Interest: One author previously worked at the University of Bradford, which owns the intellectual property of DCM.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.