Need for Dementia-Specific Training Programs

Staff who work in dementia care areas are exposed more frequently to both physical and verbal responsive behaviours as compared to who those who work in hospitals (Boström et al., 2012). Additionally, two-thirds of Licensed Practical Nurses and nursing aides (NAs) who worked in four dementia care areas experienced a physical or verbal responsive behaviour over a one month time period (Boström et al., 2012). Experiencing responsive behaviours can cause lasting effects on staff members, particularly on their physical, emotional, and mental health (Edward et al., 2014; Isaksson et al., 2011; Scott et al., 2011a, 2011b). For example, staff may question why they work in LTC homes (Needham et al., 2005), may experience burnout (Estabrooks et al., 2015), and may spend less time with the residents they care for (Scott et al., 2011a, 2011b). Thus it is important to support staff who work in LTC homes with residents with responsive behaviours. There is evidence that a dementia-specific training program can provide staff with the skills to safely minimize and de-escalate responsive behaviours (Alzheimer Society of Canada, 2010; Aylward et al., 2003; Morgan et al., 2007; Morgan et al., 2005; Scott et al., 2011a, 2011b; Snellgrove et al., 2015; Spector et al., 2013).

Within health care, there is a gap between the creation of new ideas, programs, and innovations, and the actual use of this knowledge in practice (Bradley et al., 2004; Davis et al., 2003). This gap is likely related to the large amounts of programs and initiatives with which health care providers are inundated, or the fact that the new idea or innovation did not work as well in the real work as it did in clinical trials (Greenhalgh et al., 2014). Historically, once new research findings were “pushed out” (Nutley et al., 2003), they were expected to automatically be used within practice (Ilkiw-Lavalle et al., 2002; Nutley et al., 2003). In health care settings, passive dissemination of training programs are not the most effective means for changing practice (Caspar et al., 2016; Davis et al., 2003), yet this seems to be the most common method of educating staff (Caspar et al., 2016). According to Handley, Bunn, and Goodman (2017), training programs as the only approach to engage staff in practice change is not enough to create a new culture for people with dementia.

100 3.1.3 Conceptual Framework

To effectively change the practice of staff in LTC homes, alternative approaches to passive dissemination of information must be used. Implementation science has evolved as a way to overcome the barriers (e.g., patient and clinician motivation and adherence to new ideas) that inhibit programs from being sustained in health care settings. Implementation science refers to the “scientific study of methods to promote the systematic uptake of research findings and other innovations into routine practice, and hence, to improve the quality and effectiveness of health services” (Eccles & Mittman, 2006, p. 1). In order to sustain innovations and programs,

implementation must be a planned and coordinated process that recognizes that the clinician, the patient, the context, and the entire health care system play a significant role in sustainability. The Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS)

framework was used to guide the current research, to gain an understanding of the factors that are related to the sustainability of educational programs in LTC homes.

In the i-PARIHS framework (Harvey & Kitson, 2015b), successful implementation of evidence-based practice is the result of the “facilitation of an innovation with the recipients in their (inner and outer) context” (p. 40). Successful implementation occurs when the stated goals of the project have been achieved, the clinicians and teams feel as if they “own” the program, the skills are being used in day to day practice, and there is little variability between health care settings (Harvey & Kitson, 2015b). The term sustainability will be used within this research study to reflect the idea of successful implementation, as the concept of sustainability is implied in other terms in the i-PARIHS literature (e.g., practice change, uptake of knowledge, success).

Facilitation is defined in i-PARIHS as the method for changing practice (Harvey & Kitson, 2015a). It is the “how” component of the implementation process. It involves a formal facilitator with the proper skills, who has an understanding of the innovation and the context in which the program is being implemented. Innovation is the idea or the “what” that is being implemented. Recipients are the individuals who play a significant role in the implementation process, whereas context refers to “where” the innovation is being placed. Context can be broken down into inner and outer contexts of an organization. The inner context is the exact location (e.g., LTC neighbourhood, hospital ward) where the innovation is being implemented and the organization is the larger setting in which the location of implementation is situated (e.g., LTC

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home, hospital). The outer context is the larger health care setting including all of its policies, procedures, and laws.

Within the inner context, Harvey and Kitson (2016) identified characteristics that need to be considered when working towards implementation of an innovation and sustained practice change. At the local level, these included: leadership support (both formal and informal), culture, past history of working with new innovations and practice change, evaluation and feedback mechanisms, processes for embedding change, and type of learning environment (Harvey & Kitson, 2016). At the organizational level it is important to reflect on upper management and senior leadership support, culture, history of change and implementing new ideas, and what types of learning networks are found within the organization. It is the inner contextual level (both at the location of implementation and the overall organization) that the current research is focused on (Harvey & Kitson, 2016). Specifically, this study examined the relationship between

leadership and the sustainability of a dementia-specific training program in rural LTC homes which is the rival hypothesis (to facilitation leading to the sustainability of evidence-based practice).