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Background: The protective, custodial, task-oriented care provided in residential aged care facilitates decreases health and wellbeing of residents. The aim of the study was to conduct a feasibility study of LifeFul – a 12 month reablement program in residential aged care. Methods: LifeFul was developed based on systematic reviews of reablement and staff behaviour change in residential aged care, and in consultation with aged care providers, consumers and clinicians. LifeFul includes: engaging and supporting facility leaders to facilitate organisational change, procedural changes including dedicated rostering, assigning each resident a ‘focus’ carer and focusing on the psychosocial care of residents part of handovers and staff training. The study was conducted in three Australian residential aged care facilities. A pre-post mixed methods design was used to evaluate recruitment and retention, fidelity and adherence, acceptability, enablers and barriers and suitability of outcome measures for the program. Results: Eighty of 146 residents agreed to participate at baselineand69of thesewerefollowedupat12months. One hundred and four of 157 staff participated at baseline and 85 of 123 who were still working at the facilities participated at 12 months. Staff perceived the program to be acceptable, barriers included having insufficient time, having insufficient staff, negative attitudes, misunderstanding new procedures, and lack of sufficient leadership support. Quantitative data were promising in regards to residents’ depression symptoms, functioning and social care related quality of life. Conclusion: It is feasible to deliver and evaluate LifeFul. The program could be improved through increased leadership training and support, and by focusing efforts on residents having a ‘best week’ rather than on completing a document each handover. Trial registration: Registered prospectively on 22nd January 2016 on ANZCTR369802. Keywords: Nursinghome, Residentialagedcare, Long-term care, Reablement, Restorative care, Relationship-focused care, Person-centred care Background and helps older adults to compensate for impairments The protective, custodial and task-oriented model of care with ageing or illness . Restorative care sets each person provided in residential aged care has been reported to a specific goal or desired outcome, such as adapting to have a deleterious impact on aged care residents, includ- some functional loss, or regaining confidence and capacity ing excessive disability, poor self -care [1, 2], functional to resume past activities. There is a growing body of decline, decreased physical activity and deconditioning evidence that reablement/restorative care practices in . In contrast, reablement or restorative models of care residential aged care improve residents’ physical condition focuses on the restoration and/or maintenance of function and social functioning (e.g. [5–13]). Preferences of older people support a reablement ap- proach and relationship-focused model of care. Residents * Correspondence: firstname.lastname@example.org have stated that relating to staff is one of the most import- The University of Sydney, Sydney, NSW 2006, Australia Full list of author information is available at the end of the article ant aspects of the care they receive  and want staff who © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Low et al. BMC Geriatrics (2018) 18:129 Page 2 of 12 build relationships with them and their families. Further, There is a need for a reablement program residents would like opportunities for rehabilitation, mobil- focusing on all aspects of health and/or social ity and physical exercise, social interaction and engagement care related quality of life and which specifically in meaningful leisure activities . caters for residents with cognitive impairment Aged care policy has begun to emphasize reablement and dementia. approaches. Reablement approaches are being trialed (ii) A systematic review of programs to change staff in the UK, Netherlands and New Zealand . The behavior in order to improve resident outcomes Australian Productivity Commission recommended in residential aged care . This review could that older Australians receive a flexible range of care not identify any intervention component, or and support services that meet their individual needs combination of components targeting staff, and that emphasize reablement and rehabilitation . which was more likely to result in improvement The Commonwealth Home Support Program also has in outcomes in residents, it did however show a focus on wellness, reablement and restorative care that the few studies that used theory as part of and seeks to actively promote independence . program design was more likely to be successful Successful reablement program components identified in improving resident outcomes. in the literature include establishing a new philosophy of b) Identification of relevant theory such as through care [4, 19], setting individual goals with residents or a review of organization change literature such clients [19–22], and taking a multidisciplinary approach as fundamental principles in organizational and providing ongoing training, team meetings and change management in implementing effective supervision to reinforce the approach on a daily basis changes [26, 27]. . One of the main challenges to susccessfully imple- c) Developing and describing the intervention. menting programs has been compliance by staff . The aims of this paper are to describe the development A workshop was conducted with consumers, aged care and components of reablement program for residential providers, clinicians and academics to identify important aged care – LifeFul; and conduct a feasibility study of the elements and components of a sustainable reablement evaluation of LifeFul examining recruitment and reten- focused model of care. Initial meetings and ongoing dis- tion; fidelity and adherence; acceptability, enablers and cussions were undertaken with the leadership teams at barriers; and suitability of outcome measures. participating facilities, senior executives and staff regard- ing program design and implementation. Methods LifeFul intervention development LifeFul was developed based on the MRC framework for Components of LifeFul the development of complex interventions . The The program logic for LifeFul was developed based on main steps were: a) b) and c) above and is shown in Fig. 1. The aims of the program are to improve social-care a) Identification of the evidence base through related quality of life and increase person-centred ap- (i) A literature review of reablement programs proaches to care by supporting staff to better engage In summary, most randomized controlled trials with residents and be more individualized and enabling demonstrated that reablement programs were during social, physical, recreational and daily activities. successful in improving care recipient’s health By improving engagement of residents, we think that [5, 7–9] reducing need for care or improving residents will experience better overall quality of life, as activities of daily living [11, 12], and were cost well as increased, physical and daily function, mood and effective . One trial was unsuccessful in wellbeing, and decreased agitation. In addition, staff will reducing risk of death or permanent residential experience greater work satisfaction and improvement in care . Importantly, there have been few trials delivering person-centred care. The philosophy under- that have specifically targeted persons with pinning the intended staff behaviour was person-centred dementia [6, 7]. In one study a reablement care. Person-centred care in dementia care aims to program improved overall function for maintain and nurture ‘personhood’ in dementia recog- cognitively intact residents but not for those nising the person’s identity, preferences and individual who were cognitively impaired . Reablement circumstances . Person-centred care improves the to date has focused primarily on physical and quality of life of aged care residents . Bandura’s daily function but has not emphasized social learning model and Kotter’s eight-step model for engagement with social and recreational change were the key theories underpinning staff behav- activities to improve quality of life. iour change [27, 30]. Low et al. BMC Geriatrics (2018) 18:129 Page 3 of 12 Fig. 1 Lifeful program logic Engagement and supporting facility managers was to specifically develop a good relationship with their The literature suggests that facility leadership has a key focus resident, to get to know them and their social and role in changing aged care workplace culture and in activities needs. They were encouraged to get to know research projects . Facility leaders (managers and the resident’s family and friends, and work with them deputy managers) were engaged and supported to facili- collaboratively to improve their resident’s quality of life; tate organizational change. as well as advocate for the residents during handovers, Researchers met with facility managers and their leader- case conferences, family meetings and care planning. ship teams before LifeFul commenced at each site to This did not preclude all other staff from getting to discuss the program, and to understand needs and chal- know the resident. lenges at each site. The program was tailored to each site There is some evidence that consistent assignment can (e.g. one site had a psychosocial history sheet already; we improve staff-resident relationships and some clinical adapted this rather than introducing a new form). Monthly outcomes . In two facilities, dedicated rostering was tele-conferences with each site throughout the 12 months implemented. This involved rostering the same group of program helped monitor progress and barriers which were care staff consistently within the same geographical unit jointlyaddressedbytheteam.For instance, onesiteasked that consisted of between 12 and 20 residents in the for an organization-endorsed list of activities around the facility. Consistent rostering allowed staff and residents home which residents were “allowed” to do, as there were to get to know each other better, and for staff to work as misperceptions that policies existed that prevented resi- a team. In the third facility, one unit already had dedi- dents from engaging should not be involved in housekeep- cated rostering, the remaining two units continued to ing activities (e.g. setting tables). At another site staff rotate staff across units. struggled to execute the focus resident of the week (hand- over procedure). Based on feedback the handover form All about me and procedure were changed substantively and reintro- The purpose of the All About Me document was to duced at the following training session. facilitate staff getting to know their residents better. Focus carers were trained to obtain a brief psycho-social Focus Carers and dedicated rostering history of their resident and then collaborate with the Each resident was allocated to a staff member (focus residents to complete a visual representation of their carer) who had a minimum of three shifts per week. The resident’s social and activities needs and to set achievable facility manager and leadership team aimed to match the goals (see Additional file 1: Appendix A for a fictitious focus carer with each resident based on the resident’s example). These documents were placed within resi- preferences, interests, gender, religion or cultural back- dent’s rooms (e.g. inside their wardrobe doors) and cop- ground and clinical care needs. The role of a focus carer ies were easily accessible in staff rooms. Low et al. BMC Geriatrics (2018) 18:129 Page 4 of 12 Handovers – Focus resident of the week with the Australian New Zealand Clinical Trials Registry Focus residents of the week were introduced to improve (ACTRN12616000070437). team communication about residents’ psychosocial needs, focus on quality of life and clinical care, and to reinforce Setting reablement and relationship-focused practices.. Facility The feasibility of LifeFul was evaluated within three aged managers selected a resident to focus on each week. Care care facilities in regional and metropolitan New South teams set goals based on the resident’s goals relating to Wales, in two facilities we worked with the whole recreational, physical, and independence promoting activ- facility, in one facility we worked in three of six units. ities so that residents had their ‘Best Week’ possible. To be eligible facilities has to be government accredited, Teams were to discuss the focus resident of the week not enrolled in another intervention study and executive briefly during every handover to ensure that every staff leadership and site leadership has to be willing to par- member got to know the resident better and contributed ticipate. The program was rolled out at unit level within to implementing goals. facilities as it was not feasible to implement systemic practice change with some residents, so all residents were included in the intervention. Staff training All staff were provided with four, three-hour training sessions (12 h in total) over a period of 12 months, with Study participants and recruitment processes sessions spaced 3 months apart (See Additional file 1: Staff recruitment LifeFul training and practice change Appendix B). The training program was developed to be was mandatory for all care staff (i.e., care staff, registered interactive, experiential and to support engagement with and enrolled nurses (RNs and ENs), activity officers, residents and introduce a reablement approach. As part allied health and managers) who worked on units in of these 12 h, activity officers received discipline specific which LifeFul was implemented. Staff were reimbursed training on tailoring individual and group activities and for attending training. However, participation in the lifestyle leadership, and nurses received discipline spe- evaluation was voluntary. Staff who joined the facility cific training on reablement and planning, clinical lead- after baseline were invited to subsequent training and to ership and leading handovers. participate in the evaluation at 12 months. Information Training sessions focused on the following: about the study and consent forms were given to staff by the facility manager. Session One - understanding resident’s psychosocial history and needs, goal setting, tailored approaches Resident recruitment Residents and their families were to care and activity engagement particularly for informed about the program through posters, an infor- people with dementia, communication skills and mation session and individual letters, and discussion at completing the All About Me. resident and family meetings. All permanent residents in Session Two - reablement approaches, creating participating facilities or units were invited to participate opportunities to exercise choice and control, in the evaluation of the program (N = 146). Information friendships and community in aged care, dementia statements and consent forms were given to residents or and behaviour and focus resident of the week. posted to the person responsible by the facility manager. Session Three - incidental exercise, reinforcement of Written consent was sought from residents where skills from previous sessions, and staff self-care. possible. When the resident was not able to provide Session Four - music, play and sustaining LifeFul. written consent due to cognitive or mental health related impairments, verbal consent was sought and written To accommodate staff from various shifts attending the consent was obtained from their person responsible. We training program each session was run multiple times anticipated that 50% of 146 residents (i.e., N = 73) would (Session 1 ran 9 times, Session 2 ran 11 times, Session 3 consent to the evaluation of the program. ran 9 times, and Session 4 ran 8 times). Residents who entered facilities and units after the commencement of the program were not recruited into Feasibility study the evaluation component. This is the next phase of complex intervention develop- ment according to MRC guidelines. Design The evaluation used a within group pre-post interven- Evaluation tion design. Mixed methods were used with quantitative The study has been approved by the University of and qualitative data collected. Evaluation occurred at 0 Sydney’s Ethics Committee (2015/910) and is registered and 12 months for all sites. Low et al. BMC Geriatrics (2018) 18:129 Page 5 of 12 Outcomes A total of 157 staff were approached to be part of the Recruitment and retention The number of staff and evaluation at baseline and 104 staff (66.2%) participated residents agreeing to participate in the study from those at baseline. At 12 months, 123 of these staff were still eligible within participating facilities were recorded. The working at these facilities and 85 (81.7% of baseline number and reasons for dropouts from the study were participants) participated in the evaluation. We did not also recorded. manage to collect data on how many new staff joined the program through the year, however 36 additional staff participated at 12 months. A total of 140 staff Fidelity and adherence The number of staff who participated in the evaluation over the year. Staff demo- attended each training (and those who did not) and graphics are presented in Table 3. training components delivered during training were re- corded. An audit was conducted of whether each resi- Fidelity and adherence dent was allocated a Focus carer, completion rates of All residents who consented to participate in the resident’s All About Me and resident of the week. evaluation process of the study were allocated a focus carer. Sixty-nine residents (86.3%) had an All About Acceptability, enablers and barriers These were deter- Me completed. All About Me’swerenot completed mined through evaluations completed by staff at the end because some residents did not want them (2.5%) and of each training session, monthly tele-conferences with some staff members had not completed them for their leadership teams, and focus groups and interviews at allocated resident (3.75%). 12 months with staff and managers. Thirty-six residents (45%) had been focus resident of the week. Reasons that resident’s had not been focus Suitability of quantitative measures Outcome mea- residents of the week were that some staff did not sures for residents and staff are listed in Table 1. understand how to complete the procedure, and the handovers were not scheduled and implemented by Data analyses SPSS software was used for analyses. facilities’ leadership teams. Descriptive statistics were produced for resident and The attendance of eligible staff at each session was: staff demographics, recruitment and retention, fidelity session 1–88% (110 of 125), session 2–61.79% (76 of 123), and adherence and quantitative measures. Quantitative session 3–87.80% (108 of 123) and session 4–76.07% (89 measures were examined for ceiling and floor effects, of 117). Staff missed training due to illness, annual leave, and completion rates. Multilevel linear models were forgetting, not knowing about training and having to used to examine the change in outcomes between base- cover for direct care staff. line and 12 months. These models take into account correlations between repeated measures. These analyses Acceptability, barriers and enablers took an intention-to-treat approach, as multilevel linear Acceptability – Post training session evaluations models can handle missing data at different time points. The majority of staff described the training material as In order to examine acceptability, enablers and barriers easy to understand (99.28%), relevant to their workplace we utilized qualitative content analysis  to analyze exit (99.28%) and the training helped with understanding interviews, focus groups and meeting minutes. All these (97.12%). Written comments suggested that staff enjoyed data were transcribed. Based on the transcriptions, one the activities and most of the content, however found a author (SV) systematically coded recurrent themes, these few concepts difficult to understand (e.g. Maslow’s hier- were checked by a second author (LFL) and discrepancies archy of needs, basic task analysis, stages of dementia). resolved through discussion. Acceptability – Exit interviews and focus groups Results Interviews and focus groups suggested that staff found Recruitment and retention of residents and staff the program acceptable, many staff describing benefits All 146 residents living at baseline in the selected units of the program. Staff said that LifeFul helped them to were approached to be part of the evaluation of the build better relationships with residents by taking time program and 80 residents (54.8%) consented to partici- to get to know them, listening to them, and relating to pate. Resident demographic information is presented them on a personal level. This led to increased under- in Table 2. At 12 months, 11 (13.8%) residents were stand the residents’ behaviors and needs. deceased, we were collect dataed from informants on the remaining 69 (86.3%) residents however were only “Being able to have closer insight into the client and able to interview 67 (83.8%) residents due to increased better understanding of why people do the things they cognitive impairment. do and why, they react differently with different staff” Low et al. BMC Geriatrics (2018) 18:129 Page 6 of 12 Table 1 Outcome Measures for Residents and Staff Data Instrument Descriptor Completed By Time Point Resident Staff Researcher T =0 T =12 Resident’s Everyday Experiences Resident’s Autonomy, Adult Social Care Outcomes Interview with resident and staff, xx x x x Control & Quality-of-Life Toolkit (ASCOT): Care home and observation. ASCOT measures interview schedule (CHINT-3); 8 domains: control of daily life; Care Home Resident Interview personal cleanliness and comfort; Schedule (CHResidentINT3); food and drink; personal safety; Care Home Observation social participation and involvement; Schedule (CHOBS3)  occupation; accommodation cleanliness and comfort; and dignity). Each domain is scored from 0 (high needs) to 3 (no needs) and is weighted to provide a final current QOL score. Inter-rater reliability: r = 0.618 (p < 0.001). Internal reliability Cronbach’s alpha = .71(Netten et al., 2010) Resident’s Social Social Identification and By interview. SIS measures social xxx Engagement Satisfaction (SIS)  identification and integrity and consists of 17 items organized into three subscales: social identification, satisfaction with lounge and satisfaction with life in the home. Each item is rated from 1 (completely disagree) to 7 (completely agree). Reliability Cronbach’s alpha = .70. Physical Function Short Physical Performance By interview. Battery consists of 3 tests:xxx Battery (SPPB) (Guralnik balance test, gait speed test and chair et al., 1994)  stand test. ICC = 0.82; reliability of gait speed test ICC = 0.79; reliability of chair stand test r = 0.80; reliability of tandem balance test is low (r = 0.22)(Puthoff, 2008) Depression Cornell Scale for Depression 19 items rated on severity based on xx x x x in Dementia (Alexopolous interview with resident and staff. Each et al., 1988)  item is scores from 0 (absent) to 2 (severe) and a total score > 7 suggest high probability of clinical depression. It has internal consistency Cronbach’s alpha = 0.84; inter-rater reliability range: 0.67–0.74 Daily function Disability Assessment for Informant-complete: 40 items which xx x Dementia (DAD)(Gelinas measures basic activities of daily living, et al., 1999)  instrumental activities of daily living and leisure activities. Each item is categorized into cognitive dimensions of initiation, planning and organisation and effective performance. Each item can be scored as yes (1), no (0), or not applicable. Test-retest reliability: .96; inter-rater reliability: .95 and internal consistency Cronbach’s alpha = .96. Agitation Cohen-Mansfield Agitation By interview: 29 items measuring xx x Inventory (CMAI) agitated behaviours in elderly person. (Cohen-Mansfield, 1989)  Each item is rated on frequency from 1 (never) to 7 (several times an hour). Cronbach’s alpha 0.75–0.91(in different studies); test-retest r: 0.79–0.9; inter- rater correlations: 0.76–0.96 Satisfaction with Work Nursing Home Nurse Aide NHNA-JSQ is a 21 item measure (each xx x Job Satisfaction Questionnaire item rated from 1- very poor to 10 - (NHNA-JSQ) (Castle et al., excellent) and has seven subscales – 2007) . (1) Coworkers (the relation that the person has with other workers in the Low et al. BMC Geriatrics (2018) 18:129 Page 7 of 12 Table 1 Outcome Measures for Residents and Staff (Continued) Data Instrument Descriptor Completed By Time Point Resident Staff Researcher T =0 T =12 facility), (2) Workplace Support (resources and demands of the job), (3) Work Content (the complexity and challenge of the work), (4) Work Schedule (time pressures), (5) Training (preparation required for position, (6) Rewards (benefits of the job) and (7) Quality of Care (how well nurse aides perceive residents are being cared for). The NHNA-JSQ has good internal consistency (Cronbach’s alpha > .74). Person-Centred Care Person-Centered Care P-CAT is a13 item measure (1 = disagree xx x Approach Assessment Tool (P-CAT) completely to 5 = agree completely). The (Edvardsson et al., 2010)  P-CAT measures the degree to which staff engage in person-centred care and has three subscales – personalising care (the degree to which staff and the organisation adhere to person-centred care), organisational support (the degree to which the organisation supports staff to engage in person- centred care) and environmental accessibility (the degree to which residents can access their immediate environment). The P-CAT has good internal consistency (Cronbach’s alpha = 0.84) and high retest reliability (r =.7–.9). Table 3 Staff Demographics (n = 140) “This has given me more understanding about Variable Mean (SD, range) N Missing residents on a more personal level – more knowledge or number (%) how to relate to residents” Age 42.8 (12.5, 18–67) 13 Female 124 (89%) 1 Staff also described how LifeFul helped them develop their skills by giving them specific skills in improving Born in Australia 115 (82%) 13 their communication and presenting activities. Years of Education 12.9 (2.8, 8–21) 73 Highest Education 59 “Learning new methods to make residents lives School Certificate 22 (15.7%) happier/better. Fresh ideas.” Trade Certificate 30 (21.4%) Undergraduate Degree 28 (20.0) Post-Graduate Qualification 1 (0.7%) Table 2 Resident Demographics at baseline (n = 80) Position at Organisation 1 Variable Mean (SD, range) or number (%) Age 87.6 (7.5, 63.6–98.8) Registered Nurse 18 (12.9%) Female 64 (80.0%) Activity Officer 11 (7.9%) Born Overseas 9 (11.3%) Care Staff 97 (69.3%) Marital Status Pastoral Care 1 (0.7) Single 9 (11.3%) Care Manager 4 (2.9%) Widowed 50 (62.5%) Kitchen Hand 5 (2.6%) Divorced 5(6.3%) Physiotherapist Assistant 2 (1.4%) Married/Partnered 16 (20%) Administrative Staff 1 (0.7%) Days lived in facility 1042.8 (77; 5–3804) Hours Worked (per week) 28.2 (8.0, 10–40) 17 No of Medical & Psychological 8.1 (3.2, 1–15) Years working in aged care 5.5 (5.7, 0.1–29) 16 Diagnoses facilities Low et al. BMC Geriatrics (2018) 18:129 Page 8 of 12 Staff also reported that LifeFul encouraged them to be program, or did not want to change their usual care more creative and think laterally when solving problems practices. at work. “No matter where you go you will have a small “Being creative also helps with problem solving which amount of people if something new is going to be is really important in a dementia unit.” implemented it’s always going to be negative.” Staff members noticed positive changes in the units Some staff also did not understand the new procedures they worked in. Residents were more settled as a con- (All About Me, Best Week Handover), even though they sequence of implementing some of the strategies from had received training. They were unsure about whose re- LifeFul, for instance by increasing family involvement sponsibility it was to complete the procedures, as well as and accepting family as part of the community rather the correct way of filling out the documents. than perceiving them as visitors. Staff began involving residents in the daily tasks of the unit (e.g., cleaning “Some staff suggested more clarity around forms; tables, folding clothing protectors, helping to push specifically the handovers as they were interpreted trolleys). differently to what was initially intended.” “The ‘All About Me’ sheets gave us a starting point. Staff found it more difficult implementing the program An insight into the resident’s personality. What staff with residents with later stage dementia. They described initially saw as uncooperative they now saw as proud it being more difficult to communicate, obtain informa- and independent. Physical outbursts are no longer tion, set goals for, and motivate these residents. viewed as unpredictable or malicious. Incidents of In two units where staff were rotated in and out of hitting rarely happen now, and if they do, we those areas every 3 months (i.e. where dedicated roster- understand why they happened and what our response ing was not implemented), the program appeared to should be. Staff are building up a level of trust with have the least impact based on staff feedback, even her and seeing her for who she is, and not just as though All About Me sheets and focus resident of the unmanageable negative behaviors.” week were completed. Staff found it difficult to spend time with their focus resident when working in a differ- ent area, and were not motivated to work on long-term Barriers goals for residents as they could be rotated out of that Having limited time at work, or a long list of work tasks area before being able to meet those goals. meant that staff found it difficult to spend time getting to Staff, facility managers and executive managers all com- know residents and complete new program procedures. mented on the importance of the facility leadership team (manager and unit or deputy managers) in implementing “Found it stressful, I had two focus residents plus I the program. Some staff perceived that the program was had to do that and make sure I talked to the families, not supported sufficiently by their manager. We also residents and make sure that I do my work.” observed that the program stalled if facility leadership did not continue to motivate staff and complete administra- When there was a small number of staff on each unit tive and logistical aspects of the program (e.g. assigning (sometimes only 1) the lack of time seemed to be exacer- focus carers, scheduling timetable of focus residents of the bated, as staff didn’t have team-mates to help solve week), as well as role modelling behavior (e.g. attending clinical problems, discuss daily stressors, for motivation Best Week handovers). and to change the unit atmosphere. This was an issue in low care units. “Management need to support staff at different stages of building that relationship with carers, such as, “If there were more staff, they could be more activities, starting to do the All About Me sheets, or having a more social interaction, getting to know the residents. focus resident at handover.” It would also give someone for the care staff to bounce ideas off” Enablers Negative or ambivalent attitudes of staff towards the Specific staff members were described as acting as infor- program were also described as a barrier. Some staff did mal or formal program LifeFul champions. On some units, not see program implementation as their responsibility, a key person or persons took their own initiative, in one did not prioritize or see value in implementing the facility staff were selected by facility managers and asked Low et al. BMC Geriatrics (2018) 18:129 Page 9 of 12 to support their colleagues. These champions facilitated data for 76(95%) residents at baseline and all 69 (100%) program implementation through organization, education, residents at 12 months. Some staff informants were unable motivation, resource development (e.g. obtaining materials to score domain 1 (control) of the ASCOT at baseline as for activities), and role modelling. these residents were non-communicative. The majority of scores on ASCOT domains fell into the No Needs category “Thank God for X. She helped me and all of us. If it (80.30–98.50%), suggesting the possibility of a ceiling effect wasn’t for her I wouldn’t have finished” on this tool. On the Short Physical Performance Battery (SPPB), 52 Units where staff were already working well as a team, (70.00%) and 36 (53.73%) participants were able to or where team work and morale improved through Life- complete all three subscales at baseline and 12 months, Ful, reported better success in implementing practices respectively. changes beyond the procedural aspects of the program. Some residents found it difficult to complete the seven-point Likert scale for the Social Identification and Suitability of quantitative measures for residents and staff Satisfaction Subscale (SIS), we requested those residents Residents’ scoreson the outcomesmeasuresat baseline respond Yes or No instead. At baseline and 12 months, and 12 months, and the results from multilevel linear 57 (71.25%) and 50 (74.63%) participants were able to models are reported in Table 4. On the Adult Social Care complete all three subscales on the measure. Outcome Toolkits (ASCOT) self-complete component at We obtained complete data on the three measures that baseline and 12 months, 66 (82.20%) and 52 (76.47%) resi- were completed by staff on residents’ mood, behavior dents completed them respectively. Some residents did not and daily functioning (i.e., Cornell Depression Scale, complete the ASCOT self-complete component because of Cohen Mansfield Agitation Inventory – CMAI and difficulties with communication and/or comprehension. Disability Assessment for Dementia – DAD) at baseline On the informant component of the ASCOT, we obtained and 12 months. Table 4 Resident outcomes at baseline and 12 months Outcome Measure Baseline M (SD, N) 12 Months M (SD, N) Difference between baseline and 12 months (95% confidence interval) Adult Social Care Outcome Toolkit ASCOT Domain 1 Control 0.79 (0.23, N = 76) 0.85 (0.21, N = 67) b = − 0.05 (− 0.12 to 0.01) Domain 2 Personal Hygiene 0.86 (0.14, N = 76) 0.88 (0.07, N = 67) b = − 0.02 (− 0.04 to 0.01) Domain 3 Food 0.79 (0.19, N = 76) 0.80 (0.18, N = 67) b = − 0.02 (− 0.08 to 0.04) Domain 4 Safety 0.69 (0.10, N = 76) 0.72 (0.00, N = 67) b = − 0.03 (− 0.05 to − 0.01) Domain 5 Social Participation 0.72 (0.17, N = 76) 0.76 (0.15, N = 67) b = − 0.04 (− 0.07 to 0.00) Domain 6 Occupational Engagement 0.79 (0.20, N = 76) 0.85 (0.18, N = 67) b = − 0.05, (− 0.11 to 0.00) Domain 7 Accommodation 0.85 (0.05, N = 76) 0.86 (0.00, N = 67) b = − 0.01 (− 0.17 to 0.06) Domain 8 Dignity 0.75 (0.12, N = 76) 0.78 (0.00, N = 67) b = − 0.03 (− 0.54 to − 0.01) ASCOT Total (SCRQoL) 0.84 (0.17, N = 76) 0.89 (0.12, N = 67) b = − 0.05, (− 0.08 to − 0.02) Short Physical Performance Battery (SPPB) Balance Test Total Score 1.63 (1.05, N = 52) 1.81 (1.09, N = 36) b = 0.07 (− 0.20 to 0.34) Gait Test Total Score 2.40 (0.95, N = 52) 2.64 (0.90, N = 36) b = 0.06 (− 0.24 to 0.35) Repeated Chair Stand Score 0.67 (1.06, N = 52) 0.81 (1.14, N = 36) b = 0.12 (− 0.17 to 0.42) Social Identification and Satisfaction Subscale (SIS) Social Identification 4.36 (0.96, N = 57) 4.30 (0.86, N = 50) b = 0.04 (− 0.27 to 0.35) Satisfaction with Lounge 4.79 (1.52, N = 57) 4.54 (1.34, N = 50) b = 0.26 (− 0.18 to 0.70) Satisfaction with Life in the Home 3.67 (0.72, N = 57) 3.66 (0.75, N = 50) b = 0.11 (− 0.20 to 0.42) Cornell Depression Total 7.12 (7.91, N = 80) 4.49 (4.30, N = 67) b = 2.28 (0.77 to 3.79) Cohen Mansfield Agitation Inventory 40.94 (14.31, N = 80) 40.76 (16.32, N = 67) b = − 0.32 (− 3.74 to 3.10) (CMAI) Total Disability Assessment for Dementia 41.46 (27.45, N = 80) 50.83 (32.96, N = 67) b = − 2.15 (− 10.61 to − 0.38) (DAD) Total Low et al. BMC Geriatrics (2018) 18:129 Page 10 of 12 Staff scores on the outcomes measures at baseline and were not pulled out of training to back fill for staff on leave. 12 months, and the results from multilevel linear models The original format for focus resident of the week hand- are reported in Table 5. On the Nursing Home Nurse overs had low acceptability. We changed these so that care Aide Job Satisfaction Questionnaire (NHNA-JSQ) 104 teams spent 1 week gathering information about residents (66.24%) and 95(77.24%) staff completed the outcome and setting goals, and then wrote a psychosocial care plan measure at baseline and 12 months, respectively. On the the following week. LifeFul required ongoing motivation Person-Centered Care Assessment Tool (P-CAT), 98 of staff, this might be achieved by better preparing and (62.42%) and 95 (77.24%) staff completed the outcome supporting the facility leadership team to lead the measure at baseline and 12 months, respectively. Fewer change required in the program, as well as appointing staff completed the P-CAT than the NHNA-JSQ at base- staff champions to assist with administration, execution line due to a procedural error in filling out the evalu- and motivation. ation form. There may be a ceiling effect on the proposed primary outcome measure of social care related quality of life Changes over time (the ASCOT) which makes it less sensitive to changes as Therewas areduction in residents’ depression symptoms a consequence of the program. We identified no other (Cornell Depression), improved functioning (Disability suitable measure of social-care related quality of life in Assessment for Dementia Scale) and improvement in the residential care. Increasing the scale of ASCOT items ASCOT domains of safety, occupational engagement, dig- may minimize this ceiling effect, this is currently being nity and overall quality of life (ASCOT SCRQoL). There tested by the research team that developed the scale. were no differences between baseline and 12 months on the The ceiling effect may reflect the high quality of care SPPB Subscales, SIS subscales or the CMAI. See Table 4. provided in participating facilities, and may not be repre- There were no changes over time on any of the staff sentative of Australian residential care facilities. outcome measures. See Table 5. Strengths of this study are that we worked with organizations which supported the procedural changes Discussion required in LifeFul, the research team worked closely This studydemonstratedthatitisfeasibletoimplement with facility management to monitor implementation and evaluate LifeFul, a reablement and relationship-focused and clarified, adapted and supported as needed. The program to change staff care practices in residential aged training component was commended by staff as being care facilities. LifeFul changed some staff care practices and interactive and engaging. produced promising improvements in resident outcomes. This feasibility study was not designed to produce However, there were challenges in implementation. Less generalizable results. Our small sample came from a than 80% of staff attended training. In the future we would non-representative group of three volunteer residential work more closely with facility managers to ensure that aged care facilities, all in regional areas with low propor- mandatory training attendance was policed, that staff were tions of residents from culturally and linguistically given sufficient notice about training dates, and that staff diverse backgrounds, and relatively low staff turnover Table 5 Staff Outcomes at baseline and 12 months Outcome Measure Baseline M (SD, N) 12 Months M (SD, N) Difference between baseline and 12 months (95% confidence interval) Nursing Home Nurse Aide Job Satisfaction Questionnaire (NHNA-JSQ) Co-Workers 7.64 (1.76, 104) 7.73 (1.57, 95) b = − 0.22 (− 0.56 to 0.12) Workplace Support 7.36 (1.44, 104) 7.62 (1.56, 95) b = − 0.27 (− 0.61 to 0.06) Work Content 8.76 (1.05, 104) 8.76 (1.05, 95) b = − 0.01 (− 0.25 to 0.26) Work Schedule 7.29 (1.61, 104) 7.38 (1.66, 95) b = − 0.14, (− 0.56 to 0.28) Training 8.17 (1.31, 104) 7.98 (1.60, 95) b = 0.14 (− 0.18 to 0.49) Rewards 6.19 (2.25, 104) 6.10 (2.28, 95) b = 0.08 (− 0.35 to 0.50) Quality of Care 8.58 (1.13, 104) 8.64 (1.19, 95) b = − 0.13 (− 0.38 to 0.13) Global Ratings 8.24 (1.53, 104) 7.96 (1.84, 95) b = 0.19 (− 0.18 to 0.56) Person-Centered Care Assessment Tool (P- CAT) Personalising Care 3.69 (0.75, 98) 3.79 (0.80, 95) b = − 0.13 (− 0.30 to 0.05) Organisational Support 2.76 (0.86, 98) 2. 69 (0.83, 95) b = 0.06 (− 0.18 to 0.28) Environmental Accessibility 3.18 (0.92, 98) 3.17 (0.87, 95) b = − 0.01 (− 0.22 to 0.20) Low et al. BMC Geriatrics (2018) 18:129 Page 11 of 12 (16.20% across two sites from the same organization). Anne-Nicole Casey is a post-doctoral researcher with a PhD in Psychiatry. She has research expertise in friendship and social relationships in residential The pre-post uncontrolled design means that we cannot aged care, and direct observation of human and non-human animal be certain that our intervention had a causal impact on behaviour. observed resident outcomes. We also did not correct for Henry Brodaty is Scientia Professor of Ageing and Mental Health at University of New South Wales, Co-Director of the Centre for Healthy Brain Ageing and Director multiple comparisons, or control for age, gender or of the Dementia Centre for Research Collaboration. He has expertise in assessment other characteristics. and clinical aspects of dementia, behavioural and psychological symptoms of dementia, interventions for family carers, nursing home research, and prevention of cognitive decline and Alzheimer’sdisease. Conclusions In conclusion, these results suggest that it is feasible to Ethics approval and consent to participate deliver and evaluate LifeFul. A fully-powered controlled This study was approved by the University of Sydney Human Research Ethics Committee (2015/910). All participants provided written consent before trial, including an economic analysis, is required to see if participating in the study. the program can improve resident outcomes. Competing interests Additional file Prof Merom is a member of the BMC Geriatrics Editorial Board. The other authors have declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Additional file 1: Appendix A: Fictitious sample of All About Me sheet and Appendix B: Description of LifeFul training program. (DOCX 603 kb) Publisher’sNote Abbreviations Springer Nature remains neutral with regard to jurisdictional claims in ASCOT: Adult social care outcome toolkits; CDS: Cornell depression scale; published maps and institutional affiliations. CMAI: Cohen mansfield agitation inventory; DAD: Disability assessment for dementia; EN: Enrolled nurses; NHNA-JSQ: Nursing home nurse aide-job satis- Author details 1 2 faction questionnaire; P-CAT: Person-centered care assessment tool; The University of Sydney, Sydney, NSW 2006, Australia. Western Sydney RN: Registered nurses; SIS: Social identification and satisfaction subscale; University, Campbelltown, Sydney, NSW 2560, Australia. Centre for Healthy SPPB: Short physical performance battery Brain Ageing (CHeBa), the University of New South Wales, Sydney, NSW 2052, Australia. 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