© The Association for Dementia Studies © The Association for Dementia Studies

Creating positive organisationalcultures and using person-centred

care for quality dementia care

Isabelle Latham

© The Association for Dementia Studies © The Association for Dementia Studies

CHOICE project Care Home Organisations Implementing Cultures of

Excellence

FITS into Practice Evaluation Focussed Intervention Training and

Support implement person-centred care to reduce anti-psychotic prescribing for people living with dementia

Learning to Care (PhD Study) An ethnographic study of how care workers learn to care for people living with dementia

“Person-centred Dementia Care”

Brooker & Latham (2nd Ed)...available from Nov 2015

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Focussed Intervention Training & Support FITS Project

Initial RCT: examined the effect of enhancedpsycho-social care on the use of antipsychoticmedication in residents with dementia in a carehome

FITS into Practice: rolling out that evidence-based approach across 100 care homes.

(Fossey et al, 2009)

(Brooker et al, 2015)

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Results

• Results:

0

5

10

15

20

25

30

35

40

45

50

Pro

port

ion

on

neuro

lep

tics

(%)

July 03 Oct 03 Jan 04 April 04 July 04

control Study homes

Figure 1: Fossey et al 2006 BMJ 12 NH n=347

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What is organisational culture?

The values, assumptions and norms of behaviour that influence how members of an organisation behave and interact.

These help provide working solutions to everyday problem-solving and decision-making.

This includes formal rules and overt values but also subconscious or unofficial practices

Passed on to new members as “right”: ‘the way we do things here’.

(Schien, 1990)

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Old Culture/New Culture of Care

‘Malignant Social Psychology’ was prevalent in care services and needed to be transformed into ‘Positive Person Work’ to enhance personhood of people living with dementia

Habitual actions, passed on from one worker to another and normalised in day to day work

(Kitwood, 1997)

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“Culture is the all-pervasive substance in which we grow. It is where we have our roots and from where we

absorb our nourishment. Whether it is the culture of our workplace, community, organisation or society, we

take up and use what is available to us from our cultural soil, good or bad.

Crucially, we cannot help but soak it up. We do so inevitably, often unconsciously and we cannot separate ourselves from that soil. What is in the soil affects how well we can grow, regardless of how much pruning or

attention we receive from outside,”(Brooker & Latham, 2016)

Why is it so important to think about culture?

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Individuals, groups and situations…. Why organisations matter

• The Stanford Prison Experiment; Zimbardo, (1971)

• http://www.prisonexp.org/

• Results of this experiment have been shown over and over again in different situations and across a range of social psychology research

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Apples, barrels and barrel makers…

Dispositional/Individual Factors

Bad Apples

Individual people

Situational factors

Bad Barrels

People’s roles and interactions

Systemic Factors

Bad Barrel-Makers

Oversight/structures around people’s

roles and responsibilities

Individuals are at the mercy of the situation and the situation is created by the system/s

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Why is knowing and thinking about culture so important….

“One doesn’t appreciate the power of Situations to transform one’s thinking, feeling and action when caught in its grip. A

person in the claws of The System just goes along, doing what emerges as a natural way to respond at the time in that place…

We all want to believe in our inner power, our sense of personal agency, to resist external situational forces…

For many that belief of personal power to resist powerful situational and systemic forces is little more than an illusion…

We are best able to avoid , prevent, challenge and change such negative situational forces only by recognising their potential

power to infect us,” (Zimbardo, 2007, pp 181/211)

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The power of the situation is the power of….

Rules to shape behaviour: They establish what is necessary, acceptable & over time ‘come to have an arbitrary life of their own’

Role performance: We learn the role (and its behaviours) rather than being ourselves

Anonymity and deindividuation: If no one notices, then no one cares

Zimbardo, 2007

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The power of the situation is the power of….

Cognitive Dissonance: When there is a discrepancy between our behaviour and beliefs we will change one or the other to reduce the dissonance.

“when (dissonance) happens, smart people do stupid things, sane people do crazy things and moral people do immoral things…After they have done them, they offer

‘good’ rationalisations of (what they did),”

Dehumanised Relationships: Us and Them - characterised by objectification and empty of emotional or empathic content.

Dehumanised situations: loss of freedom, lack of privacy, loss of identity; separation from past, community, families and (their) normal reality.

Zimbardo, 2007

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The features of a positive care culture

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Overall Findings: care experiences

• Care Homes providing excellent care: Consistently inspiring, creative and sensitive approaches

• Care Homes aiming to provide good care but often providing poor care:

- Little engagement for long periods

- Neglectful, restrictive and abusive practices

- Insensitive and inconsistent support

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Overall Findings: relationship to culture

Positive care experiences were facilitated by:

Shared norms of practice, values and assumptions about care.

Seven elements of a ‘positive culture’ were present.

Poor care experiences were unusual and infrequent.

Positive care experiences were impeded by:

Lack of shared norms, values and assumptions.

Some, but not all, of the seven elements of positive culture were present

Positive care experiences were dependent on individual staff

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Positive Care Cultures

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Positive care culture

The features of positive care culture are interconnected. They help to facilitate and

reinforce each other.

A positive care culture requires constant work related to all of the features to create and

sustain it

Any service improvement or intervention must account for

all features

Beliefs and values lead to actions

that create a positive care

culture

Positive care culture enables

norms and assumptions

of care practice

Norms of care practice reinforce

beliefs, values and actions

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Shared purpose in providing the best person-centred care

• Everyone had the same understanding of what person-centred care means in their home

• This understanding was based on practical, everyday actions and their impact on residents

When different staff at one home were asked what advice

they would give to a new member of staff, all of them

independently answered:

“get to know your residents”

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A sense of community between all involved in the care home

• All residents, staff and visitors have opportunities to be involved in home life

• Residents are known throughout the home and enjoy everyday experiences

• Friendship-like interactions with and between residents

“When G’s niece was visiting I saw her chatting and welcomed

by staff. Smiles and ‘how are you?’ She belongs here, she is not just “next of kin” , she is a

friend to us,” (Researcher Observations)

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Staff are empowered to take responsibility for resident well-being through active management processes

• Staff were both willing and able to make decisions and take action for resident well-being

• Management & leadership practices either encouraged or discouraged this

Fred’s key worker was highly responsible and had good insight

into why he often reacted physically to staff. However,

management were seen to exclude care staff from discussions about

Fred’s care.

When the manager was asked about the key worker’s relationship

with Fred she replied: “I haven’t really thought about why she’s so

good with him.”

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Management & leadership practices that empowered staff:

Practical and emotional

support

Physically present

Clearly defined expectations and

boundaries of different roles

Responsive to problems and

ideas

Diffuse (there were sub-levels of leadership)

United and strong in

decision-making

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Managers ensure that external factors do not have a negative impact on care delivery

• Managers protected the daily work of staff from the impact of external factors by absorbing it or translating it into resident-focussed action

• External factors included: regulatory & organisational requirements, family requests and financial pressures.

“Making sure the T’s are crossed and the I’s are dotted, that’s what the job is mostly about now. The amount of

time staff have to sit down and spend on care plans,” (Manager)

this led to a typical observation of care practice:

“Carer asks about dietary records for residents who haven’t eaten yet.

Another carer replies ‘just record a spoonful’.

Care plans are a care task here rather than a product, to the extent

that we record something even when it hasn’t been done,”

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Openness to change for the benefit of residents

• Ongoing and gradual change pursued for the benefit of residents was the norm

• When the benefit for residents was clear it helped others to accept and support the change

“When we first had animals I had terrible trouble (with organisation’s management committee), because

they said ‘we don’t like animals, why have you got them in?’ So we talked to them, wrote it in the newsletter, the benefit that it gave to residents. Just kept talking about it and saying

‘but it’s not going to go away, whether you think it’s good or not,

we know it is,’” (Manager)

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The care home environment is used for the benefit of residents

• Less about design, more about the use of space and environment

• Constant reflection on the environment’s impact on residents and care

• Organisational decisions must take this into account

Bedrooms have memory boxes outside. Betty’s is

covered in smudged finger marks. There is a poem

inside that talks about how much Betty likes to see her name; it says she will point

and smile. Betty’s bedroom door does not

have her name on it. (Observation)

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Person-centred activity and engagement is integral to care work

• Activity and engagement with residents were integral to care work, not added extras

• Worthwhile activity and engagement was defined as what is meaningful residents, not pre-determined.

“I appreciate what (care staff) have to do. It is tiring and I do feel that to then come on board with activities is quite hard for them. So I’m trying

to support them as much as I can with giving them lists of ideas of

things they can do, making sure that I’ve actually got the equipment so

that they can come and say, look we want to do this today. ”

(activities coordinator)

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Positive Care Cultures

Service improvement

initiatives

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Acknowledgements CHOICE PROJECT

This research is funded through the PANICOA programme by the Department of Health and Comic Relief. The views expressed in this presentation are those of the authors and do not reflect those of the Department of Health or Comic Relief.

With special thanks to:

• The care homes (including residents, relatives, visitors and staff) who volunteered to take part the project

• Our research team colleagues at University of East Anglia, University of Stirling and Cardiff University

© The Association for Dementia Studies © The Association for Dementia Studies

Acknowledgements: FITS into Practice

The FITS into Practice programme was led by the Association for Dementia Studies, University of Worcester and funded by the Alzheimer’s Society and HC-One.

It built on an original randomised controlled trial of the FITS programme conducted at King’s College London, in association with Oxford University, University of Newcastle and Oxford Health NHS Trust. Copyright of the original FITS manual is held by Dr Jane Fossey (Oxford Health NHS Trust) and Dr Ian James (University of Newcastle).

With special thanks to all the Dementia Care Coaches & care homes who took part for their many examples of good practice, dedication, creative thinking, compassion and hard work implementing learning in their homes and making a difference to the lives of people with dementia in their care.

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References• Brooker, D & Latham, I (2016) Person-centred Dementia Care London, Jessica Kingsley

• Brooker, D.: Latham,I.; Evans,S.; Jacobson,N.;Perry,W.;Bray,J.;Ballard,C.; Fossey,J. & Pickett,J. (2015) FITS into Practice: translating research into practice in reducing the use of anti-psychotic medication for people with dementia living in care homes Ageing & Mental Health available online: DOI:10.1080/13607863.2015.1063102

• Fossey, J., Ballard, C., Juszczak, E., James, I., Alder, N., Jacoby, R., & Howard, R. (2006). Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: A cluster randomised trial. British Medical Journal, 332. 756758.

• Fossey, J., & James, I. (2008). Evidence-based approaches for improving dementia care in care homes. London: Alzheimer’s Society.

• Killett, A et al., “Digging deep: how organisational culture affects care home residents' experiences” Ageing and Society, available on: CJO2014. doi:10.1017/S0144686X14001111.

• Schein, E. (1990) ‘Organizational culture.’ American Psychologist 45, 2, 109–19.

• www.midstaffpublicinquiry.com

• www.http://www.prisonexp.org/

• Zimbardo, P (2007) The Lucifer Effect London, Rider)

Full reports of CHOICE, FITS into Practice and PIECE-dem research are available via: http://www.worc.ac.uk/dementia

© The Association for Dementia Studies

Thank you

Isabelle Latham

Association for Dementia Studies, University of Worcester

For more information contact: i.latham@worc.ac.uk

Visit the ADS Website: http://www.worcester.ac.uk/dementia

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