Dementia buddying as a vehicle for person-centred care? The performance of a volunteer-led pilot on two hospital wards

Abstract

Objectives

To understand and explain whether a dementia buddies pilot introduced into two adjacent mental health hospital wards in England was achieving its aim of enhancing person-centred care.

Methods

The research used a cultural lens to evaluate the dementia buddies pilot. It comprised 20 in-depth semi-structured interviews with staff, volunteers and carers in the two wards where the pilot was introduced.

Results

The pilot’s ability to deliver positive outcomes depended on its compatibility with the culture of the ward and it performed better in the ward where a person-centred culture of care already existed. In this ward, the pilot became a catalyst for improved experience among patients, carers and staff, whereas in the second ward, the pilot faced resistance from staff and achieved less.

Conclusions

This finding underlines the benefit of focusing on workplace culture to understand the performance of volunteer-led initiatives. It also shows that existing ward culture is a determining factor in the capacity for dementia buddy schemes to act as vehicles for culture change.

Keywords

dementia discipline: health policy discipline: social policy elderly person-centred care workplace culture

Introduction

Dementia buddies projects in which volunteers befriend people with dementia reflect two recent health care priorities in the United Kingdom (UK): person-centred care and volunteering in dementia care and health care more generally. As a form of befriending, dementia buddying carries an inherent emphasis on recognizing people’s individuality and uniqueness.¹ An emphasis on individuality is also seen as key to person-centred care of people with dementia.² The volunteer befriender may therefore be viewed not only as having the capacity to directly increase the amount of individual care a patient receives but also, by practising person-centred care themselves, to promote it more widely in the ward setting.

In response to calls for a greater emphasis on personhood and person-centred care in dementia care,^3,4 interest in psychosocial interventions, such as befriending and buddying, is growing. There remains, however, a lack of rigorous evaluation of such schemes.^5,6

This paper reports on an evaluation of a dementia buddies pilot in two adjacent mental health hospital wards. Its aim was to understand and explain whether the scheme was achieving its objective of enhancing person-centred care. We focused on the cultural aspects of this situation, seeing the introduction of the dementia buddies scheme as an exercise in bringing one set of predispositions, understandings and practices of care into the domain of another. Consideration of compatibility between workplace cultures therefore came to the fore.

Key concepts and existing knowledge

Person-centred care can be interpreted in many ways,⁷ and this study draws on the VIPS framework developed by Brooker and Latham³ to define it. From this perspective, the main elements of person-centred care are: Valuing people with dementia and those who care for them; treating people as Individuals; looking at the world from the Perspective of the person with dementia; and offering a positive Social environment.³

Befriending and buddying in dementia care

Since befriending constitutes a subset of psychosocial interventions, research addressing dementia buddying of hospital in patients is less common and comes to mixed conclusions. Positive impacts of in-patient dementia buddying on people with dementia are found to include improved levels of engagement and nutrition, and lowered distress.^8,9 Dementia buddying can also herald a reduction in staff workload,⁹ and volunteers may enable staff to themselves focus more on delivering person-centred care.⁴ Less positively, buddying can create tensions between volunteers and paid staff,⁹ a finding echoed in more general assessments of volunteering in health care settings.¹⁰

Although these studies discuss person-centred care and highlight the organizational tensions of mixing paid and volunteer models of work, they do not fully explore the role of culture in influencing what happens when dementia buddy schemes are introduced into health care settings. Yet culture is a key factor in dementia buddying, both because it champions a person-centred culture of care and because it represents the introduction of new policy or practice, in this case volunteer befriending, and so raises the issue of compatibility with existing working practices.

Culture change in health care settings

While culture is well recognized to be an amorphous concept, in the context of health care settings, there is agreement that it refers to the set of shared understandings and predispositions which shape work practices.^11,12 The focus in this study is on workplace culture, which is understood to both influence and be influenced by organizational and corporate cultures.¹¹ In the UK, recognition that notorious cases of failure in health care can be partly due to a poor culture of care has boosted research into how to change culture to improve patient experience, particularly through person-centred care.^11,12 Studies from the United States and Canadian long-term care culture change movement contribute to the understanding that culture change entails a thorough-going process, in which an emphasis on person-centred care is just one part.^13,14 Understanding the complexity of achieving culture change includes recognition of the potential discrepancies between espoused values and actual practice.¹⁵ This may manifest at the various levels where cultures exist within organizations, including at ward level. A focus on this level is important as it is where health care is delivered and experienced^11,16 and because wards should be seen as microsystems which exhibit their own microcultures.¹⁷

Other studies are concerned not with culture change but, rather, the role of culture in the implementation of new policy more generally.¹⁸ This issue has also been addressed through a Bourdieusian conceptual framework in various health care research studies.^19,20 These studies demonstrate that if new policy is introduced which is in conflict with the habitus or culture of a ward, it will be resisted.^19,20 While this study does not follow an explicitly Bourdieusian framework, the understanding of culture it employs similarly takes the view that multiple factors determine workplace culture, including spoken and unspoken norms, organizational hierarchies, and workplace processes and reward systems. By taking this view of culture, it is possible to postulate that the introduction of a dementia buddies scheme has the capacity to affect ward culture as a whole.

How cultures of care arise

An alternative strand of literature focuses on understanding how cultures of care arise since this is seen as a necessary precursor to any efforts to manage them. These studies are based on conceiving culture as a metaphor for an organization, rather than a variable.²¹ Conceiving culture as a variable of an organization invites a modernist orientation towards finding out how that culture might be managed; whereas if culture is conceived as a metaphor, describing an organization, the research focus tends to a post-modernist concern with uncovering the processes of meaning-making within that organization. What these studies contribute to the present discussion is the understanding that the written and unwritten rules and routines which characterize nurses’ work constitute the caring culture of a ward.²² The way caring is actually practised on a ward arises from the interplay between the meaning that nurses bring to caring and the context within which they practise care.

Volunteering in health care settings

A well-recognized ordering of the literature on volunteerism is the volunteer process model, which divides studies into chronological groups: the antecedents of volunteering; the experiences of volunteering; and the consequences of volunteering for those who volunteer.^23,24 Among these categories, the experiences of volunteering is the most relevant to assessing a particular scheme’s performance, but this is the category which has received least attention.²⁴ Studies which do look at the volunteer experience are often oriented to explaining volunteer retention.²⁴ This is seen to be contingent on the organizational socialization of volunteers: their relationships inside the organization in which they volunteer and their affective bonds with staff and other volunteers.^25,26 This touches on culture but it concerns individual volunteers’ relations in the organization where volunteering happens, rather than acknowledging that they may be part of a volunteer scheme with its own culture.

Studies also highlight the tension between paid staff and volunteers both generally²⁶ and in health care.¹⁰ However, the focus is on tension over role boundaries, rather than on any mismatch in culture between the volunteer setting and the volunteer scheme. The individualist nature of much literature on volunteering makes considerations of the volunteer as part of a group or scheme more peripheral. Some critique this individualistic perspective, stressing that volunteer activities are embedded in interpersonal relations with others as well as specific organizations, programmes and settings.²⁷ But while a body of theoretical work has flowed from this critique of theory, its representation in empirical work querying the volunteer experience is still relatively uncommon.^24,26

Summary

As this brief review has shown, there are many studies on dementia buddying and, separately, on the challenges of managing and understanding the cultures of care in health care settings. As far as we are aware, however, few studies apply a cultural lens to the issue of introducing dementia buddy schemes within hospital wards. There are also studies which look at culture in volunteering but not the culture of volunteer schemes and there is scant attention to cultural fit in relation to how volunteer schemes perform in hospital wards. This study therefore applies a cultural lens to the performance of a dementia buddies pilot in hospital wards.

Methods

Context

The dementia buddies scheme

The scheme evolved from a charitable foundation set up by a family in honour of their father who had dementia. After a training programme, buddies were allocated to patients, with the aim of building a strong and supportive friendship. The buddy engaged in whatever pastime best suited the person with dementia, recognizing their individuality and past life activities and experiences.

The pilot sites

The scheme was piloted when the charitable foundation joined forces with an NHS Foundation Trust which provided community health, mental health and learning disability services. This led, in summer 2013, to the introduction of the scheme into two hospital wards providing mental health services for older people. The two wards, referred to here as Summer and Spring wards, had certain features in common: both were 24-bed, mixed-sex wards, and had almost identical staffing levels. However, the purpose of the wards differed. Summer ward was an assessment unit for older people with dementia. Spring ward was a continuing care ward for older people with specialist mental health needs related to a diagnosis of dementia. Consequently, the typical length of time patients stayed in the wards differed, from a few weeks in Summer ward, to several months in Spring ward.

Research aim and design

The aims of the research were to understand and explain whether the pilot was achieving its objective of enhancing person-centred care. This made it suited to qualitative enquiry, which is also recognized to have particular advantages in understanding culture in health care organizations.¹⁵

The evaluation ran from March 2014 to March 2015. The first phase comprised three key informant interviews to identify what the people involved in designing and piloting the intervention envisaged its aims to be. The second phase aimed to assess whether, in practice, the goals were being achieved and the reasons behind this (see Figure 1).

Figure 1.

Data collection stages.

Participants

Researchers conducted semi-structured interviews with three key informants about the aims of the pilot and with 20 participants comprising clinical and support staff, carers, and buddies, as described in Table 1.

Table 1.

Interview participants – Phase two.

Participant type	Number associated with Spring ward	Number associated with Summer ward	Number associated with both wards	Total number interviewed
Clinical and support staff	5	4		9
Carers/relatives (‘Association with ward’ means this is where their relative stayed)	2	3	2	7
Buddies			4	4

Procedure

Ethical approval

Approval from the Anglo Ruskin University ethics board was obtained for this research. In order to protect participant identities, details of the site where the research took place have been disguised and demographic details kept to a minimum.

Recruitment

Key informants were recruited via direct emails and telephone calls from the research team. Other participants were self-selecting. Staff were recruited via a message from the research team sent to them by the senior nurse. Relatives were recruited via a research information session held at a carer support group in the hospital. Buddies were recruited via a research information session at a training event and via the head of the scheme. All participants gave fully informed consent.

Interviews

Key informant interviews were conducted face-to-face at the hospital. The interviews lasted between 30 min and an hour. The interviews with staff, buddies and relatives typically took the same length of time. Sixteen of these were face-to-face and four were conducted by phone (for interviewee convenience). Fourteen interviews took place at the hospital and two in the participants’ homes. All interviews were recorded and transcribed. The interviewer asked open-ended questions designed to elicit participants’ views on the purpose of the pilot, their personal experience of it, its strengths and weaknesses and, in the process, to explore their views on caring.

Analysis

The interviews were analysed using inductive thematic coding in a manner informed by Miles and Huberman,²⁸ moving from line-by-line descriptive coding to pattern coding. Coding decisions were discussed among the research team and the coding system developed critically and iteratively, including the memoing of in-process coding decisions.

Findings from phase one

Key informant understandings of pilot’s aims

The key informant interviews were conducted with the ward sisters on Spring and Summer wards and with the head of the buddy pilot. It was clear that there was some variation in the emphasis these players placed on the purposes of the pilot. The head of the pilot viewed it primarily in terms of its capacity to support relatives of people with dementia. This reflected the fact that she had cared for her father when he had dementia and experienced the tensions of balancing that role with her other roles and obligations. The ward sisters identified support for carers as an aim, but both put more emphasis on delivering additional individualized care to patients. One ward sister also mentioned the importance of one-to-one care in Care Quality Commission requirements.

Findings from phase two

In analysing the interviews, two main themes emerged. The first concerned attitudes to person-centred care, which subdivided into positive and negative attitudes. The second concerned attitudes to the role of the buddies as volunteers, also subdivided into positive and negative. These attitudes also reflected the interviewees’ underlying culture of caring. It was clear too that negative attitudes clustered in comments from Summer ward staff and in buddies’ and relatives’ description of their experiences of Summer ward.

Positive attitudes to person-centred care

There were various ways that buddies demonstrated a person-centred culture of care, as understood in the VIPS model.³ The attitude they took to people who were unable to communicate verbally indicated that they did not assume this meant the person was incapable of responding to them. This showed an ability to take the perspective of the person with dementia. For example, buddies described patients affectionately squeezing their hands or smiling and laughing while they were talking to them, saying their mood seemed to improve. They spoke about people they buddied not only as dementia patients but as people with rich past lives, in this case demonstrating that they thought of them as individuals. This was facilitated by the head of the buddying pilot giving them background information about the person with dementia:

You come in with some idea of what that person liked and that is absolutely great because you can buddy them on the information you’ve got - what they enjoy. (Buddy A, working on both wards)

The buddies’ person-centred attitude towards the patients seemed, in turn, to have a postive impact on the patients’ relatives. They saw the buddies as giving the patients the same kind of attention they themselves gave and therefore substituting for their visits and enabling them to take a break. This attitude was underlined by carers being asked to supply buddies with information about the patients’ prior lives. One relative described how buddies ‘talk to rather than talk around ’ patients. This is another example of valuing people with dementia which is part of a person-centred care ethos.

Relatives said that the buddies’ visits enabled them to do things such as go on holiday, attend to their own health and fitness, and maintain their social connections. They also talked of the buddies enabling them to ‘stand back a bit, rather than being the one that takes it all’. This lessened their emotional strain.

It’s strange but you feel they [the buddies] are relieving me of some of the stress and as soon as you accept that… You have looked after them for so long but it’s letting go really. (Relative A, Spring ward)

Although staff rarely used the term person-centred care, their fundamental support for it was evident in the way some described the benefits of the buddies scheme. These staff displayed understanding that the patients were individuals, with rich past lives, and current preferences:

The patients are not just existing but receiving something that is individual to them and their likes and dislikes. (Nurse E, Spring ward)

I look at the patients and think, this is how I would want my Mum and Dad treated – someone to talk to. (Nurse F, Spring ward)

One nurse from Spring ward said that a patient who very rarely had visitors told a buddy about aspects of their history previously unknown to staff. This, according to the nurse, enabled staff to respond to the patient at a more individual level. Again this exemplifies a person-centred ethos of care.

Some staff appreciated buddies giving patients the kind of care they would like to give themselves:

They’ve got the time to sit there and say, “Do you like this picture and do you remember this?”. It’s nice that they are engaging in it… It’s a shame we haven’t got time to sit there and look through pictures with them. (Nurse A, Spring ward)

These comments evidence a genuine buy-in to the values of person-centred care. All of the staff interviewees from Spring ward expressed similar views, suggesting a shared caring culture. This was not the case on Summer ward, however.

Lack of fundamental buy-in to person-centred care

Interviews with Summer ward staff indicated a different workplace culture, in which person-centred care was less evident. This was exemplified in comments from some staff that failed to recognize the individuality of patients. One staff member referred to patients as ‘this lot’, saying they were particularly unable to benefit from the buddies’ visits but that the ‘next lot’ might be more able to. These comments seemed to reflect the organizational imperatives of Summer ward as an assessment unit and hence a place where patients stay for less time, making it seem more like ‘a production line’. Another Summer ward staff member also commented that patients were unable to benefit from dementia buddies. This was despite the fact that Summer ward patients often had less advanced dementia than those on Spring ward. This staff member recommended that the buddies ‘go and see someone that can do stuff and remember’. These views were echoed by a third Summer ward staff member, who described the buddies as ‘a waste of space’ and suggested that they would be more useful in a non-specialist hospital where there are patients ‘they could talk to’.

Evidence of a lack of fundamental support for person-centred care was also clear in comments which displayed a disregard for the past lives of people with dementia:

You get some gist of what they were and what they’ve done but to me – I know it sounds horrible – I just look after these [sic] as they are now. (Nurse D, Summer ward)

These comments suggest the nurse had a primarily task-based attitude but felt conflicted about it, perhaps reflecting a tension over competing cultural pressures.

Not all Summer ward staff displayed a lack of fundamental support for person-centred care but it was a feature only of Summer ward interviews. The comments from buddies and carers about Summer ward also reinforced the impression of a relative lack of a person-centred ethos of care on that ward, as illustrated in the next section.

Support for dementia buddies as a volunteer pilot

The dementia buddies pilot was not only about buddying but it was also about volunteering. The research showed that attitudes to this aspect of the pilot also varied between the two wards and among the different groups of research participants. Relatives valued the voluntary nature of the scheme for enabling a different kind of relationship with patients than staff were able to provide. On the positive side, this entailed the buddies being more like friends. But some carers also valued the buddies for their capacity, as volunteers, to ‘keep a watchful eye’ on staff. This attitude reflected carers’ feelings about a possible lack of person-centred care associated with Summer ward and was expressed by relatives of two patients who had both spent time there. One carer described this ‘lookout’ role of buddies in the following way:

I just think, if something was wrong or they [the staff ] spoke to my husband not right, they [the buddies] would probably tell me. (Relative B, Summer ward)

Effects of buddies being volunteers were also identified by clinical staff on both wards. Some saw benefits in buddies being able to operate outside key constraints, in particular, the constraints of targets. One nurse compared them to occupational therapists:

They [the buddies] have got no obligation to see if this person responds to holding the ball or whatever… If you’ve got someone whose job depends on demonstrating that this particular thing worked, then they are maybe going to be feeling they have to push the person to do something. (Nurse B, Spring ward)

One Spring ward nurse said the presence of buddies served to remind staff to be compassionate themselves. This illustrated her underlying support for compassionate care and also showed the capacity of the pilot to enhance support for the values of person-centred care such as taking the perspective of the person with dementia. Others said the buddy scheme made their job easier because buddy visits left patients in a more relaxed, calm mood. The motivations of the buddies were also applauded.

It is reassuring that someone has given up their time to come and be with someone in hospital…I think it’s nice that these people are doing it out of the kindness of their heart. You can get nurses coming in because of the money so the compassion is not always there but it is with these people because they believe in what they are doing. (Nurse B, Spring ward)

As with the example above, this statement indicates the respect the nurse has for compassionate care, even though she may not believe it is always practised.

Lack of support for the voluntary nature of dementia buddies

Two Summer ward staff said the voluntary nature of the scheme hampered patients’ ability to benefit from it. This was because buddies were on the ward for relatively short periods and at pre-determined times, which meant their visit might coincide with the patient being asleep or unreceptive. They felt that paid staff were better placed to respond to patients because they were there more often. This illustrated tensions in Summer ward about role boundaries, which some staff said made them feel insecure about their jobs.

Some buddies also identified negative attitudes towards the buddy pilot, three unfavourably comparing Summer ward with Spring ward in this respect. One buddy talked of a ‘them and us’ feeling on Summer ward and said she sensed that the staff felt buddies were ‘trying to take their job away’. Another described feeling ‘more comfortable’ on Spring ward than the on Summer ward; a third talked of not finding the staff on Summer ward ‘quite as nice’ as on Spring ward.

The interviews also identfied tensions around work systems. Two buddies talked about the difficulties they encountered in accessing the ward, having to ring a bell, rather than being given the door code. This made them feel they were not fully trusted and they disliked having to disturb busy staff to gain entry. Accessing the patients themselves presented similar problems, leading to what some buddies described as ‘wasted journeys’. One buddy said that frustration over this issue was part of what prompted her to give up buddying.

Discussion

Overall, the research suggested a clear distinction between the caring cultures of the two wards: in Spring ward, there was evidence that a person-centred culture of care was fully embedded among staff, whereas on Summer ward, this was less apparent. The key VIPS elements of a person-centred culture of care were evident in interviews with Spring ward staff, whose attitude to the buddies and the buddy scheme evidenced that they valued the patients, treated them as individuals themselves or appreciated others doing so, were able to take the patient’s perspective, and welcomed them having a positive social environment.³ On Summer ward, by comparison, there was less evidence of all of these elements and some evidence of their absence.

The research indicated that part of the reason for this cultural discrepancy lay in the different priorities of the two wards, which resulted from one being a continuing care ward and the other an assessment ward. In Spring ward, there was evidence that the support for person-centred care was facilitated by long-term relations with patients, whereas the lack of support for person-centred care on Summer ward seemed related to the relatively rapid throughput of patients and the consequent adoption of a ‘production line’ mentality by staff. This association between the culture of caring and organizational imperatives echoes other research.²² It does not imply, however, that organizational imperatives alone accounted for the culture of the ward; the position of this study was that this was just one factor among many likely to have contributed to the culture.^11,12 This observation about the link between work priorities and culture also corroborates research which highlights the tensions in acute hospitals between the need to focus on dignified care as well as to meet standardized targets.¹² The Royal College of Nursing in the UK has argued that this places staff in an invidious position as they try simultaneously to meet both objectives.²⁹ Comments from staff on Summer ward which suggested discomfort about the way they themselves regarded patients appeared to bear this out.

The research also indicated that the differing cultures of the two wards helped explain the differing performance of the buddies pilot on each one. The scheme performed better on the ward where there was greater compatibility between its culture and the ward culture. A number of inter-related benefits flowed from the introduction of the pilot on the ward where it was culturally compatible and a number of disbenefits on the ward where it was not.

On Spring ward, the pilot acted as a catalyst for positive change, reminding nurses of patients’ personhood, and it brought the comfort of seeing patients get more care of a kind they felt was beneficial. Some of these positive benefits of inpatient dementia buddying have been identified in other research,^8,9 but not explained in terms of cultural compatibility and the consequent cycle of positive benefits. This situation contrasted with Summer ward, where person-centred care was not universally embedded in the caring culture partly, it seemed, because of the priorities of a short-term assessment unit. Coupled with feelings of job insecurity, this meant the pilot was less welcome among staff and produced a cycle of disbenefits: there were more reports of wasted journeys, of buddies feeling unwelcome and of relatives feeling distrustful of staff. This situation echoes other research which has found that poor communication between carers of people with dementia and staff can lead to negative cycles of interaction, including carers engaging in hypervigilant monitoring.³⁰ It also chimes with previous research into inpatient dementia buddies schemes, which has noted, on the positive side, that they may enable more focus on person-centred care and, on the negative side, that they can lead to feelings of tension between paid staff and volunteers.^8,9 The difference between previous research and this study is that, in this case, the tension is explained partly in terms of the schemes being vehicles of a particular culture of care and therefore prone to succeed or fail on the basis of the compatibility between the introduced culture and the existing culture.

Overall, the study suggests that the pilot was able not only to increase the amount of person-centred care patients received, by virtue of the extra one-to-one time buddies spent with patients, but it also enhanced a person-centred culture of care in the ward more generally, where there was evidence of this already being present.

Although the findings may be highly context-dependent, they raise the wider possibility that the success of new intiatives such as a dementia buddies schemes depends in part on a culturally conducive setting. This suggestion is supported by other research which has looked at failed attempts to change practice at ward level and ascribed that failure to the poor fit with ward culture or habitus.^18–20

From a theoretical perspective, the study stands as an example of the utility of considering culture at the workplace level and to conceive it as arising from the particular mix of numerous contributory factors at that level.^11,12 This has proven a useful model for understanding culture change but as this study also demonstrates, a focus on workplace culture can help explain the success or failure of new intitiatives such as dementia buddying by highlighting their cultural dimension.

Limitations

Participants in the interviews were self-selecting so their views cannot be taken to be representative of views of the wider sub-set they belonged to. This moderates the finding that a person-centred culture of care was more embedded on Spring ward. However, corroborative comments from buddies and relatives do lend support to this claim. This research was confined to a particular instance of volunteer buddying so the findings, as with much qualitative research, are highly context-dependent.

Conclusion

The dementia buddy pilot at the centre of this research was not a culturally neutral phenomenon but, rather, embodied a person-centred culture of care. As such, when it was piloted, its performance was found to depend on the compatibility between the caring culture of the scheme and the caring culture of the ward where it was introduced. Where these two aligned, the scheme acted as a catalyst for positive change, was welcomed by staff and carers, and led to satisfaction among the buddies. Where the two did not align, the scheme led to a cycle of disbenefits among these groups. This implies that before introducing a volunteer schemes into care settings, it is advisable to consider the cultural compatibility between the scheme and the setting. Where there is a level of incompatibility, some prior groundwork on changing the culture of the receiving environment may bring benefits.

Footnotes

Acknowledgements

We wish to thank all study participants and our colleague Alison Hirst for her input into discussions on culture in public sector organizations.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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