Improving Quality of Work life for Care Providers by Fostering the Emotional well-being of Persons with Dementia: A Cluster-randomized Trial of a Nursing Intervention in German long-term Care Settings

Abstract

We tested the feasibility of a nursing intervention (DEMIAN) in routine care and its effects on care providers’ job satisfaction, motivation, and work strain.

This cluster-randomized trial was conducted in 20 German long-term care facilities. We randomly assigned 20 facilities to an intervention group (84 care providers, 42 residents with dementia) or a control group (96 care providers, 42 residents with dementia). Intervention group providers received two training days on the intervention; 68 providers attended both training days. Sixty two providers completed both baseline and follow-up questionnaires.

Trained providers created individualized mini-intervention plans for participating residents. Control group residents received ‘usual care’. Intervention group providers stated that the intervention was feasible and helped them improve emotional well-being of residents with dementia. We found significantly decreased time pressure and decreased job dissatisfaction for intervention group providers.

DEMIAN is an effective and pragmatic contribution to implementing person-centred care in long-term care, with positive effects on providers’ working conditions.

Keywords

persons living with dementia emotional well-being nursing intervention quality of life cluster-randomized controlled trial

Introduction

Quality of life has become a fundamental goal for nursing in general, and particularly in the context of a person living with dementia in long-term care (LTC).¹ This study emphasizes the importance of fostering emotional well-being of persons with dementia systematically as one approach of creating ‘quality of the moment’. As Pringle (2003) thoughtfully stated, care providers should strive ‘to ensure that the persons for whom they are responsible have the best possible day they can have, in addition to ensuring that they are clean, warm, and comfortable’ (p. 9). Rather than ‘quality of life,’ Pringle (2003, p. 9) argued that the more appropriate focus is ‘quality of daily life’ or even ‘quality of the moment.’ However, care providers are often absorbed in task-oriented care such as bathing, dressing and providing food (Mallidou, Cummings, Schalm, & Estabrooks, 2013) and often lack time for conversations (Knopp-Sihota, Niehaus, Squires, Norton, & Estabrooks, 2015; Ward, Vass, Aggarwal, Garfiled, & Cynyk, 2008). Nursing research should find ‘effective ways of ensuring that these people [sic; e.g. persons with dementia] have the opportunity to live as rich, interesting, and pleasurable lives as they are capable of’ (Pringle, 2003, p. 7). Or, as others framed it, to recognize the importance of ‘the little things’ (Ryan & McKenna, 2014, p. 38). In our previous study, we proposed and tested the DEMIAN intervention to identify moments of individual well-being for persons with dementia and develop care situations that may be catalysts for well-being. In this study, we investigated the feasibility of applying the intervention in care practice, and its effects on care providers’ job satisfaction, motivation and work strain. We also assessed if care providers applied the learning obtained in DEMIAN to their broader work context.

Emotionality of persons with dementia

Persons with dementia experience emotions right to the end of life and are able to express them verbally or non-verbally long into their disease progression (Boller, Verny, Hugonot-Diener, & Saxton, 2002; Re, 2003). Emotions are influenced by characteristics of the care situation that are amenable to care mini-interventions; examples are participating in recreational activities or having memories prompted to trigger emotional conditions (Finnema et al., 2005; Schreiner, Yamamoto, & Shiotani, 2005). These mini-interventions can be applied because, even in severe stages of dementia, persons attribute meaning to individuals, memories, objects, and situations (Bär, 2010; Beil, 2012; Ehret, 2008) and have concern for other people (Boller et al., 2002; Kontos, 2011). A rich body of evidence from subjective well-being research emphasizes the importance of positive affect for subjective quality of life, both at the level of intense discrete affect states (emotions such as happiness, anger, or fear (cf. Russell & Feldman Barrett, 1999)) and less intense but more prevalent mood states (e.g. alert, tense, relaxed (cf. Diener, Sandvik, & Pavot, 1991)). Research points to different sets of determinants and mechanisms for negative versus positive affect states, such as the dual channel model (Lawton, 2001). However, the potential of affect states to indicate subjective well-being as a central outcome of care have not yet been fully explored (Kaspar & Hartig, 2016).

Unfortunately, persons with dementia are often not able to arrange meaningful situations or approach people significant to them. In LTC facilities, care providers may assist residents in finding opportunities to experience positive emotions such as joy and interest to enhance well-being. Person-centred care approaches hold high potential for co-producing quality of life and subjective well-being (Edvardsson, Sandman, & Borell, 2014). Most approaches share a focus on ‘recurring themes of knowing the person, the centrality of values, biography, relationships, seeing beyond the immediate needs and authenticity’ (McCormack, 2004, p. 31). Person-centred care approaches emphasize the role of care providers in enabling meaningful situations and relationships for persons with dementia in LTC facilities and in involving care staff, other residents, and family (McCormack, Roberts, Meyer, Morgan, & Boscart, 2012).

Nursing intervention targeting everyday experiences of positive emotions and well-being

Boelsma, Baur, Woelders, and Abma’s (2014) statement that ‘small things matter’ (p. 45) accords with Pringle’s (2003) suggestion to focus on improving the ‘quality of the moment’ (p. 9) when caring for persons with dementia. The DEMIAN intervention, developed through a seven-year research and evaluation process, echoes these calls. Its main objectives are to gather information on meaningful situations for each individual and to use this knowledge in planning and providing care. DEMIAN focuses on two key domains of well-being and meaning of life: emotional attachment and positive everyday situations.

Emotional attachment. Both the number and the characteristics of social contacts change with age (e.g. socio-emotional selectivity theory (Carstensen, 1991)). There are also often severe functional losses in very old age that go along with a shift of priorities from processes of activity to processes of belonging (e.g. agency belonging model (Wahl, Iwarsson, & Oswald, 2012)). Bär (2010) found that attachment to life itself or to significant others – real or imagined – is related to experiences of a meaningful life of persons with dementia. An appropriate understanding of significant others relies critically on self-reports. However, changes in autobiographical memory (Naylor & Clare, 2008) and verbal difficulties raise challenges for persons with dementia in remembering and talking about their significant others.

Positive everyday situations are characterized by experience of positive emotions like joy, interest, or pleasure. Nonverbal expressions of emotions, especially facial and bodily expressions, persist into severe dementia (Kontos, 2011; Re, 2003). Assuming that these expressions are not merely random but based on characteristics of a situation, positive emotionality can indicate an experience of coherence and congruence in the person–environment interaction. In some cases, these can be interpreted as hints to significant others of persons with dementia.

Empirical evidence for effectiveness of fostering positive emotions

Our DEMIAN intervention was developed and evaluated in two studies²: 1) at the level of the individual care recipient (e.g. Bär et al., 2006; Böggemann et al., 2008) and 2) at the level of care providers and institutional settings. Objectives of the first study (2004–2007) were to a) develop a methodology for identifying meaningful situations of persons with dementia and b) test the effects of systematically utilizing these situations on residents’ well-being. For the first objective, we assessed what triggers the experience of meaningful situations for persons with dementia in LTC. For the second objective, we examined to what extent fostering of such meaningful situations by care providers could change the emotional status of persons with dementia. We conducted qualitative interviews with selected residents, their families, and care providers, and facilitated case conferences with each care team to discuss the validity and potential of the information gathered. In these case conferences, care providers decided which kind(s) of situation(s) could be provided realistically within their daily practice and at a minimum risk to the person with dementia. We developed mini-intervention plans for participating residents and helped care providers to define the pivotal characteristics of situations to elicit residents’ well-being. Finally, we asked care providers to use these individualized mini-intervention plans to create and support meaningful situations as frequently as possible across a three-week intervention period.

We tested this approach in a quasi-experimental, two-group, pre–post-test study design (cf. Böggemann et al., 2008). We included 25 LTC facilities that provided integrative care for persons with dementia and randomly selected 97 residents, stratified by severity of their dementia-related symptoms (mild–moderate–severe; determined with the Global Deterioration Scale (Reisberg, Ferris, de Leon, & Crook, 1988)). Meaningful situations characterized by positive emotions (e.g. expression of joy looking at a family photo or sensual pleasure eating a piece of chocolate) were identified for all persons with dementia. Mini-interventions to foster these situations (e.g. conversation about family photos or offering a piece of chocolate) were derived and individualized mini-intervention plans developed for all participating residents. The number of mini-interventions included in individual plans was unrelated to dementia stage (Böggemann et al., 2008).

Care providers documented the mini-interventions provided and the reactions of the persons with dementia to decide on changes in strategies or modifications of mini-interventions. In analysing this documentation, we found a high situational success rate. Because the rate of expressed positive emotions was higher in the treatment group than the control group (CG) (who received conversations about general topics like the weather), we concluded that the DEMIAN approach does foster emotional well-being by creating meaningful situations for persons with dementia (cf. Bär et al., 2006; Böggemann et al., 2008). DEMIAN enhances the experienced quality of the moment and makes moments matter. It is a useful operationalization of person-centred care and extends a pool of care concepts aiming at similar effects (e.g. Jeon et al., 2012; McKeown, Clarke, Ingleton, Ryan, & Repper, 2010).

Research questions

Based on the promising findings of the first study, in this study, we investigated three research questions:

Feasibility for care providers: Can care providers identify situations that persons with dementia experience as meaningful? Does the DEMIAN intervention help care providers to identify the active ingredients of those meaningful situations? Are care providers trained in DEMIAN able to plan mini-interventions in order to create meaningful situations for residents? Can care staff apply these mini-interventions systematically during the study period? How often do they provide these mini-interventions?

Effects on care providers: What are DEMIAN’s effects on care providers’ job satisfaction, job motivation, and perceived work strain?

Applying the DEMIAN intervention to a broader work context: Do care providers who are trained in an emotion-focused nursing intervention transfer this attentional focus to other areas of their work that are unrelated to the intervention?

Methods

Study design

We conducted a pragmatic, two-group, cluster-randomized controlled trial with baseline assessment (T1), intervention period, and post-intervention follow-up (T2) (cf. Kruse et al., 2010). The intervention period encompassed two full days of training within two weeks and a six-week implementation phase. Control group facilities provided care as usual during the intervention period and received a half-day training course after study completion.

Study setting and sample

The research team created comprehensive lists of all registered LTC facilities in five geographical regions of Southern Germany. A researcher not involved in recruiting facilities or carrying out the intervention assigned a computer-generated random number to each facility on the list. In order of their random number, facilities were assigned alternately to the CG or the intervention group (IG) and then approached sequentially. We contacted the facility managers via mail and phone, checked eligibility of the facility, and invited the managers to participate in the study. Inclusion criteria on facility level were a) an integrative care approach of persons with dementia (no special care unit for residents with dementia); and b) the willingness to include two units, or if a facility had only one unit, the willingness to include this unit. On staff level the inclusion criteria were a) a Registered Nurses (RNs)³ certificate; and b) staff had to be employed at least three months in this facility. On resident level was required a) a diagnosis of dementia; and b) residents had to live there for three months or longer. Furthermore, facilities had to identify at least five RNs and two persons with dementia per unit.

In total, we aimed to include 20 LTC facilities, 200 RNs, and 80 persons with dementia. These numbers were considered the upper limit of what facilities could invest in light of staff shortages and the prospect of including even more personnel in delivering highly individualized mini-interventions. Post hoc sensitivity analysis for the 180 included care providers revealed that despite the drop-out of one IG facility after T1 the study was sufficiently powered (1 − β = 0.95) to identify small effect sizes (f = 0.135) in our study outcomes (α = 0.05) between the two study groups, using repeated measures analysis of variance (correlation among repeated measures = 0.5) with within and between interactions.

Study intervention

Participating care providers from IG facilities received two days of in-house training on the DEMIAN intervention. During the following six-week implementation phase, we asked trained providers to provide emotion-focused mini-interventions for participating residents.

Theoretical foundations of the intervention were Strauss’ and colleagues concept of sentimental work (Strauss, Fagerhaugh, Suczek, & Wiener, 1980), Benner and Wrubel’s (1997) understanding of caring, and the life story work approach (see Berendonk & Stanek, 2010; Berendonk et al., 2011; Stanek, Berendonk, Schönit, Kaspar, & Kruse, 2010). To maximize feasibility for care providers, we aligned DEMIAN with the steps of the nursing process (Berendonk, Stanek, Kaspar, Schönit, & Kruse, 2010; Stanek et al., 2010), a common and mandatory nursing management tool in German LTC facilities.

Intervention steps

RNs were in charge of planning and carrying out mini-interventions and evaluating effects on situational emotional well-being of the person with dementia. The DEMIAN intervention includes: 1) collecting information, 2) identifying aspects that make a situation positive and meaningful, 3) defining objectives of the intervention, 4) developing an intervention plan (see supplementary file for an example), including instructions on creating meaningful situations via case conferences,⁴ 5) carrying out the intervention, and 6) preparing a formative and summative evaluation of intervention effectiveness.

Gathering information on meaningful situations is a crucial step in DEMIAN. We developed three different approaches to collecting that information: 1) conversations with and observations of persons with dementia, augmented by the use of photos (private and public) and other materials to evoke memories and by an adaptive, person-centred style of communication; 2) conversations with relatives and friends (our first study demonstrated that significant others can provide important additional biographical information); and 3) exchange among all care team members, including direct care providers and other facility staff who have contact with residents (e.g. housekeeping staff). We developed conversation guidelines for all three approaches based on the queries about meaningful situations that were most successful in our first study.

The trained RNs were in charge of all intervention steps, but they were encouraged to involve all team members, relatives, volunteers, etc. in those steps. Numerous mini-interventions were designed to be implemented in daily routines. Therefore, RNs asked people in contact with residents to select and carry out mini-interventions that most suited their individual preferences, skills, and relationship with the persons with dementia.

Care provider training

The training course was piloted in one LTC facility that participated in our first study and the training protocol was optimized accordingly. Main training objectives were to teach care providers the intervention steps and how to develop strategies for using the intervention in their daily practice. Two researchers provided the training (CB facilitated all trainings). We used varied methods (e.g. presentations, videos, group discussions, teamwork practices) and followed the same protocol in all trainings.

The first training day gave background information on experienced affect, mood states in dementia, emotion recognition, and emotion-related interaction (verbal and nonverbal). We discussed with providers the objectives of the DEMIAN intervention and its implementation in the nursing process. We introduced assessment strategies to gather information about meaningful situations. Between the two training days, care providers were asked to gather information about meaningful situations for selected residents using the three approaches described above. Collected information was used on the second training day. We instructed care providers on how to 1) evaluate collected information, 2) develop mini-interventions that are feasible in their daily practice, and 3) think about necessary conditions and items needed to provide the mini-interventions. Case conferences were conducted for all selected residents. The last part of the second training day focused on dissemination strategies.

Following the training phase, care providers facilitated, carried out, and evaluated mini-interventions with persons with dementia over six weeks. After approximately three weeks, researchers offered providers in each IG facility a coaching session. In addition, IG providers received continuous telephone support.

Outcome measurements

Primary outcomes

Participating care providers from IG and CG facilities completed self-report questionnaires at T1 and T2. The questionnaires contained the screening instrument for job strain in human service work (BHD) (Hacker & Reinhold, 1999) and a modified version of the ‘Task and Job Analysis Tool – Residential LTC Version’ (TAA-A) (Büssing & Glaser, 2002; Glaser, Lampert, & Weigl, 2007).

The BHD is a short self-report scale to assess job demands and capture psychological work strain in the organizational, task-related, and client-related domains of the human service sector (Hacker & Reinhold, 1999). It includes emotional exhaustion, aversion to clients, reactive shielding, job dissatisfaction, and lack of intrinsic motivation and analyses stress and burnout resulting from subjective job and task perceptions. It contains 38 items that relate workplace characteristics to subjective job experiences on a seven-point Likert scale. Fischer (2006) and Hacker (2009) demonstrated the BHD’s validity to assess psychological work strain. Internal consistency was adequate in our study sample for all subscales except reactive shielding (alpha = 0.85–0.74 vs. 0.47).

With the TAA-A, we collected information on the perceived support and demand structures of job tasks and the subjective evaluation of job motivation and satisfaction. The TAA-A was developed as a screening instrument for use in LTC facilities and has demonstrated scale reliability and validity in a number of studies (Büssing, Glaser, & Höge, 1999; Büssing, Glaser, Höge, & Giesenbauer, 2000). Its focus is on workplace conditions and prerequisites rather than subjective workplace experiences, but it considers employees as experts for their work area and the preferred informants for workplace conditions. The original scale has six domains and 127 items, but we developed a short version for this study together with the original authors. Our version has 44 items capturing the domains of task-related resources, personal resources, task-related stressors, and job demands through responses on a five-point Likert scale. Scale reliability was adequate in our sample for all TAA-A domains (alpha = 0.93–0.73).

Secondary outcomes

At both T1 and T2, we analysed DEMIAN documentation forms and nursing documentation for all selected residents. Furthermore, we evaluated providers’ experiences with DEMIAN in feedback sessions at every IG facility (qualitative results reported by Stanek et al. (2010)).

DEMIAN documentation forms – evaluation of intervention provision

We asked the trained providers to document, in a separate DEMIAN form, whether they provided a mini-intervention during the six-week intervention, what kind of intervention they provided, what effects it had on residents, and who provided the mini-intervention.

Nursing documentation – evaluation of intervention effects on work context

We analysed the prevalence of references to residents’ emotional states in their nursing documentation. These references are potential indicators of care providers translating the emotion-related DEMIAN intervention to their general care practice. Care documentation is mandatory for nursing practice in Germany and part of the daily care routine, independent of our study. We analysed documentation for persons with dementia in both study groups, including all documentation available at baseline (eight weeks retrospective) and during the eight-week intervention period. An increase in documentation of emotional states or their precursors and consequences, as a non-reactive measure, could provide strong evidence for translation of the DEMIAN intervention to routine care practice.

Analysis

Statistical analysis

We used parametric (Chi-square and z) statistics to assess group differences in provider characteristics and study outcomes between the two study groups at baseline (randomization check). To assess the effect of the DEMIAN intervention on our study outcomes, we used mixed-effects regression models based on robust estimates of standard errors to account for clustering effects of outcome assessments (T1 and T2) nested within providers and providers nested within facilities. Dependent variables were our study outcomes (BHD and TAA-A and subscales), independent variable was the study group assignment (IG vs. CG). We calculated facility-level intra-class correlations. Computations were done with SAS 9.3 and Mplus 7 software.

Qualitative analysis

We used qualitative content analysis (Mayring, 2008) to analyse 1) the intervention plans and forms in which IG providers documented the mini-interventions to foster meaningful situations and 2) all conversations during coaching and feedback sessions.

Two researchers analysed the nursing documentation for 80 persons with dementia to determine whether participating providers transferred their knowledge about emotion-focused care to other areas of their work. Specifically, each assessor coded the types of emotional states documented for the residents and counted the number of entries referring to emotional states. The analysis followed the circumplex model of positive and negative affect (Russell & Feldman Barrett, 1999) and mood states (Diener et al., 1991). Research team members compared and discussed their analyses in meetings; in cases of discrepancies (27.9% of the analysed records), a third person analysed the data entry and the team agreed on a final version.

Ethics approval

Ethics approval was granted by the Research Ethics Committee of the Medical Faculty, University of Heidelberg, Germany (approval number S-207/2007). Study participation was voluntary. Before data collection, written informed consent was completed by participating persons with dementia or their family representatives and by care providers.

Results

Sample

Figure 1 illustrates selection and flow of participating LTC facilities, care providers, and persons with dementia.

Figure 1.

Flow of participating LTC facilities, care providers and residents through this study.

LTC facilities

On average, 86.6 residents (SD = 41.5, range 37–181) lived in each participating LTC facility and facilities had 2.8 units (SD = 1.5, range 1–7). Eleven facilities were run by private providers and nine by non-profit organizations.

Care providers

At baseline, a total of 180 care providers (IG = 84; CG = 96) participated in the study (Table 1); all were nominated by managers as being most suitable to participate. Although we aimed to include primarily RNs, as outlined in the inclusion criteria, only 74% of providers were RNs (Table 1). Facility Directors of Care were unwilling to send more RNs to our two-day training because of staff shortage or unit size. A few smaller facilities included fewer than ten providers in the study.

Table 1.

Baseline characteristics of participating care providers.

	Intervention group			Control group
	N	Mean (SD)	Range	N	Mean (SD)	Range
Characteristics
Age (years)	78	41.8 (10.2)	23.0–59.0	93	38.5 (11.9)	19.0–62.0
Work experience in current facility (years)	79	6.9 (6.5)	0.01–27.7	96	6.9 (6.4)	0.01–25.3
Work experience in nursing overall (years)	73	13.1 (8.4)	1.0–36.0	75	11.6 (7.9)	0.01–35.0
	N	Percent		N	Percent
Female	70	87.5		81	85.3
Male	10	12.5		14	14.7
Qualifications
RN (3-year vocational training)	56	71.8		69	75.8
HCA (1-year training)	4	5.1		8	8.8
Nursing students	15	19.2		14	14.3
Other	3	3.9		1	1.1
Additional certificate
Geronto-psychiatric nursing	3	4.1		4	4.3

HCA: health care aide; RN: Registered Nurse; SD: standard deviation.

In line with our expectations, randomization resulted in no significant differences in sample characteristics between the two study groups.

Feasibility of the DEMIAN intervention

In total, 76 care providers attended training day 1 and 72 attended day 2. Nine providers attended only day 1, four providers only day 2. Training days were missed for sickness and staff shortages requiring providers to work. Overall, 68 providers attended both days.

Setting up intervention plans

IG providers were able to identify and describe meaningful situations for all selected residents. However, they needed various levels of support to translate these meaningful situations into intervention strategies for persons with dementia. Providers in two of the nine IG facilities managed well in setting up individualized intervention plans on their own, but most providers needed support from the facilitating researchers, mainly for two reasons. First, providers reported a lack of ideas and creativity on how to create feasible mini-interventions from information gathered on residents. Some had difficulty translating and adapting biographical information about meaningful situations of a person with dementia to the current situation of the resident, especially those with severe dementia. Second, some providers had good ideas in case conferences for mini-interventions but had difficulty writing ideas down in an understandable way for their colleagues who lacked the DEMIAN intervention training.

Mini-interventions developed

Overall, providers developed individual intervention plans for all selected residents. The plans included, on average, 4.8 intervention strategies (range 3–8). In total, 171 mini-interventions were developed, which could be assigned to 16 overarching categories (Table 2).

Table 2.

Categories of intervention strategies developed for individualized intervention plans.

Category of intervention strategy	Example(s)
Foster connections to persons important to the person with dementia	Show photograph of close relatives; read a letter from a relative who lives abroad
Give individual appreciation	Pay the person a compliment, e.g. for a necklace or new haircut
Reminiscences – foster memories or pay attention to narrations	Show photos; focus on individually important topics in conversation; talk about individual decoration of resident’s room
Foster experiences of competence and usefulness	Talk about former profession; foster helpfulness, e.g. resident takes care of plants on the unit
Foster spirituality	Integrate the person in church festivals; share a prayer or say a psalm
Foster experiences in and with nature	Support a person with dementia to take care of plants; visit the garden; share illustrated books about mountains
Specific touch	Give a hug; caress; give a hand massage
Provide specific food or beverages	Offer a piece of chocolate; offer a favourite beverage with dinner
Foster skills	Let a person guess origin of license plates; let them complete proverbs
Music	Sing together; let him play the harmonica; play favourite songs
Foster contact with animals	Provide contact with pets; share illustrated books about animals
Provide nursing tasks in a specific way	Use preferred aromas for bathing; apply eau de perfume; emphasize a personal style
Foster habits	Support rituals, e.g. sitting on the toilet for a long time reading magazines
Support contact to community	Support contact to other residents; include person in group activities; foster relationships
Enable withdrawal and privacy	Enable a person with dementia to experience quiet and recovery; allow a person to have a key to her room; provide recovery time in beloved armchair
Take meaningful objects into account	Provide contact with a doll, radio, or cuddly toy

Mini-interventions provided

Care providers in IG facilities documented on average 14 mini-interventions per resident (SD = 9.6, range 1–38 interventions) during the 56-day (six-week) implementation phase. For nearly 28% of persons with dementia, all mini-interventions outlined in their individualized intervention plans were realized and documented across the implementation phase. However, for approximately one-third of residents, 50% or fewer suggested mini-interventions were realized.

Effects on care providers’ job satisfaction, job motivation, and work load

At baseline (T1), 84 providers from IG facilities and 96 providers from CG facilities returned questionnaires. Response rates at follow-up (T2) were lower (IG = 71, CG = 87), and included providers who did not respond at T1. Data on job demands and stressors were therefore available from 62 IG and 85 CG providers for analysis of change across the study interval (Table 3).

Table 3.

Providers’ perceived job demands and job strain at baseline (T1) and follow-up (T2).

	Baseline (T1)				Follow-up (T2)
	Intervention group (N = 62)		Control group (N = 85)		Intervention group (N = 62)		Control group (N = 85)
	Mean (SD)	Range	Mean (SD)	Range	Mean (SD)	Range	Mean (SD)	Range
Screening tool for job strain in human service work (BHD)
Emotional exhaustion (12 items)	36.7 (12.1)	13.0–66.0	34.9 (11.9)	15.0–73.0	35.2 (12.8)	12.0–59.0	35.5 (14.1)	14.0–76.0
Lack of intrinsic motivation (eight items)	22.3 (9.0)	8.0–50.0	22.6 (8.8)	8.0–56.0	22.1 (8.7)	8.0–42.0	23.6 (9.1)	8.0–49.0
Job dissatisfaction (seven items)	19.2 (7.8)	7.0–40.0	18.4 (7.4)	7.0–43.0	18.4 (9.0)	5.0–42.0	19.3 (9.0)	7.0–42.0
Client aversion (five items)	11.4 (4.7)	4.0–23.0	11.4 (5.2)	4.0–29.0	10.5 (4.6)	5.0–21.0	11.3 (5.5)	5.0–35.0
Reactive shielding (six items)	27.3 (4.8)	13.0–38.0	25.5 (5.2)	11.0–36.0	26.9 (4.9)	14.0–37.0	25.7 (3.9)	18.0–38.0
Task and job analysis tool – LTC (TAA-A)
Job demands (three subscales, 10 items)	3.9 (0.7)	1.9–5.0	4.0 (0.5)	2.5–5.0	3.9 (0.6)	2.2–5.0	3.9 (0.6)	1.7–5.0
Task-related resources (two subscales, 10 items)	3.9 (0.7)	1.9–5.0	3.9 (0.6)	2.2–5.0	3.9 (0.6)	2.5–5.0	3.8 (0.7)	2.1–5.0
Personal resources (two items)	3.2 (1.1)	1.0–5.0	3.4 (1.0)	1.0–5.0	3.2 (1.0)	1.0–5.0	3.3 (1.1)	1.0–5.0
Task-related stressors (four subscales, 22 items)	2.5 (0.7)	1.1–4.0	2.3 (0.6)	1.1–3.8	2.3 (0.6)	1.0–3.3	2.3 (0.6)	1.1–3.9

LTC: long-term care; SD: standard deviation.

The facility-level intra-class correlations of job strain and task affordances (the proportion of observed variance in these outcomes that can be attributed to differences between LTC facilities) were low (<5%). Higher intra-class correlations were found for characteristics of the care recipients (BHD client aversion, 12.7%), the institutional advanced vocational training culture (TAA-A learning affordances, 11.6%), or organizational characteristics of the LTC facilities (e.g. personal resources, 28.4%; time pressure, 12.5%).

Both IG and CG providers showed equivalent average levels of BHD job strain at baseline: 21% of IG providers and 19% of CG providers reported job dissatisfaction levels considered to be ‘critical’ by BHD scoring guidelines (within the top 30% of the norm population distribution, Hacker & Reinhold, 1999) (Figure 2). The percentage of providers with critical job dissatisfaction levels increased similarly in both groups during the study. In the IG, however, the percentage of providers with positive job dissatisfaction scores (greater job satisfaction) increased during the study (group difference of increase marginally significant, p = 0.053).

Figure 2.

Levels of job dissatisfaction (subscale of the BHD) by study group and by time of assessment.

Baseline levels of all TAA-A subscales were the same between study groups. IG providers reported slightly higher task-related stressors at baseline, especially with respect to time pressure, but differences were not statistically significant. Most TAA-A outcomes did not differ significantly between study groups after the intervention. However, time pressure (one subscale of the TAA-A task-related stressors scale) dropped significantly in the IG compared to the CG (β = 0.283, standard error = 0.127, p = .026). This corresponds to a medium effect size (Cohen’s D = 0.50 (Cohen, 1988)), for which this study is adequately powered (1−β = 0.911).

A more conservative intention-to-treat approach that retains all randomized providers in the final analysis confirms these findings. With only one follow-up measure, however, the last-observation-carried-forward strategy is equivalent to assuming no change across the intervention phase for T1 providers without follow-up measurement; we do not consider this a well-informed assumption.

Intervention effects on broader work context

Overall, entries in the nursing documentation of selected residents varied substantially in number and content. One in six records (16–17%) included an emotion- or mood-related reference at the baseline assessment. The overall number of entries was comparable at baseline and follow-up (T1 and T2). However, at T2 we observed significantly more entries related to residents’ emotional well-being in the IG than in the CG (23% versus 16%; β = −6.189, standard error = 2.803, p = .027). Taking into account the clustered structure of the data, though, the estimated effect is only marginally significant (β = −6.189, standard error = 3.623, p = .088) and effect size is small to medium (Cohen’s D = 0.48). Post hoc power analysis revealed that, with only 80 care documentation entries available, the study was underpowered to substantiate the estimated small to medium effect of the intervention on documentation of emotional conditions (1–β = 0.685).

Discussion

Recently, a growing number of more studies and research groups have focused on meaningful situations for persons with dementia and the importance of connecting residents with personally meaningful memories, interests, and activities (e.g. Cooney et al., 2012; Edvardsson, Fetherstonhaugh, & Nay, 2010; Han, Radel, McDowd, & Sabata, 2016; Milte et al., 2016).

We kept DEMIAN’s core idea deliberately simple to make the intervention feasible for care providers in multi-professional teams, including volunteers and relatives. However, as with other person-centred care interventions, RNs play a central role in managing, delegating, and evaluating DEMIAN (McCormack et al., 2012). DEMIAN provides an opportunity for care providers to develop individual, tailored interventions that are adapted to everyday life and capabilities of persons with dementia. Hence, it can support staff in employing person-centred care. As providers in an Australian study emphasized, just collecting information about residents is not enough: ‘this knowledge had to be translated into practice and actively used in the provision of care so that it could be person-centred’ (Edvardsson et al., 2010, p. 2614). By systematically considering information about persons with dementia, care providers can create meaningful situations for them (Edvardsson et al., 2010). This strengthens the role of care providers in providing holistic care, beyond direct care tasks such as bathing residents and serving meals.

However, DEMIAN is not a comprehensive intervention that covers all areas of caring and nursing; for example, unlike other approaches, it does not aim to prevent behavioural and psychological symptoms of dementia or loss of abilities. Instead, its objectives are increases in situational well-being and experiences of meaning and purpose. Quality of the moment is the target, hence ‘small’ (Boelsma et al., 2014) or ‘little’ (Ryan & McKenna, 2014) things matter. This particular resource-oriented focus means that DEMIAN should be complemented by other approaches, such as the ‘bathing without a battle’ intervention to avoid situations during bathing or showering that are challenging for persons with dementia and their care providers (Gozalo, Prakash, Qato, Sloane, & Mor, 2014).

DEMIAN’s starting point is an individual assessment of meaningful situations for a person with dementia, including multiple perspectives but emphasizing the view of the individual person (Milte et al., 2016; van den Brandt-van Heek, 2011). DEMIAN is distinct from other approaches that sometimes ‘unintentionally reduce the person to the sum of biographical and care details assembled from family and staff (…) overlooking the person’ (de Medeiros & Doyle, 2013, p. 83). With DEMIAN, care staff take into account past experiences and attachments but focus foremost on currently meaningful objects and moments. Persons with dementia and their families also contribute individual needs and meaningful activities to care plans (Cooney et al., 2014).

The feasibility of the DEMIAN intervention

Care providers were able to gather information on emotional attachment and meaningful situations for all persons with dementia. Therefore, we conclude that the used DEMIAN conversation guides are suitable. However, providers often needed support in creatively tailoring interventions to residents’ needs and in describing interventions clearly and comprehensively for colleagues. This aligns with analyses of care plans by German public authorities, which revealed difficulties of care providers in planning and writing individual care interventions (MDS, 2012).

The types of strategies developed in this study are similar to the intervention categories reported in other studies: providing meaningful situations in which persons with dementia can feel competent, skilled, and useful (Milte et al., 2016); connecting a person with dementia with other persons (Han et al., 2016); respecting individual preferences for personal appearance (Ryan & McKenna, 2014; Ward, Campbell, & Keady, 2014); taking into account individual food preferences (Ryan & McKenna, 2014); providing individual appreciation (Milte et al., 2016); fostering reminiscence (Harmer & Orrell, 2008; Milte et al., 2016); connecting persons with nature (Han et al., 2016; Milte et al., 2016); showing respect for personal space and privacy (Milte et al., 2016); and supporting individual music preferences (McDermott, Orell, & Ridder, 2014). We emphasize that strategies have overarching commonalities, but DEMIAN requires tailoring interventions individually for each person with dementia (Cahill & Diaz-Ponce, 2011; Han et al., 2016).

We found great variety in documentation of mini-interventions by care providers. Documentation load is already high for providers and providers likely gave more mini-interventions than they actually documented. This was confirmed in many feedback conversations (cf. Kruse et al., 2010). Providers also reported lack of time to provide mini-interventions in a systematic way; lack of time is a common problem in LTC (Cooney et al., 2014; Knopp-Sihota et al., 2015). In addition, providers were not always aware of our supplemental mini-intervention documentation form.

Intervention effects on care providers

Average levels of perceived work-related burden, as captured by the BHD, were invariant across study groups and measurement occasions. This is not surprising; LTC facilities are complex environments in which multiple factors influence measured job satisfaction, motivation, and strain.

In light of the many factors that contribute to perceptions of workplace settings and job strain, and given the additional time and resource restrictions that come with any form of intervention program in LTC, we consider it striking that time pressure was significantly reduced in the IG after they used the DEMIAN intervention. Because initial work strain was measured before training of care providers, we conclude that this effect cannot be linked back to additional demands on IG providers.

We found a marginally significant decrease in job dissatisfaction in the IG that engaged in co-producing well-being for persons with dementia. We conclude that co-producing well-being is a mutual process of give and take, rather than a unidirectional service task for the exclusive benefit of the care recipient. This interpretation is supported by other scholars who concluded that person-centred care interventions can lead to less job stress and strain and to more job satisfaction (Edvardsson et al., 2014; Jeon et al., 2012; McCormack et al., 2010).

These results point to the potential of the DEMIAN intervention to increase job satisfaction above a common level. On the other hand, job dissatisfaction increased for both the IG and the CG during the study. We cannot dismiss the possibility that unmet expectations and frustrated ambitions from participating in the study had adverse effects on individual providers.

Intervention effects on broader work context

We hypothesized that an intervention that integrates well into daily care routines will also augment the attention of care providers to affective and mood states of persons with dementia. This was partly substantiated by an increase of emotion-related entries in nursing documentation (small to moderate effect size for the IG only). Although this study is underpowered to substantiate this effect, we consider this marginally significant finding striking because our analysis of residents’ care documentation was not explicitly described to providers in the intervention protocol itself. It can be seen as a non-reactive measure of intervention effects. In current LTC, documenting care to address emotional states plays a subordinate role to documenting care tasks geared to functional status of a resident. Given the low awareness of emotion-related interaction as care work, and hence its low base rates in care documentation practice, the documentation increase we observed is strong evidence of the study intervention translating into everyday care practice.

Limitations

Level of intervention

DEMIAN deliberately focuses on positive situations. Care providers receive little guidance on addressing negative states in residents. Many mini-interventions may in fact help overcome feelings of boredom or sadness for persons with dementia through giving them attention, communicating with them, distracting them from negative feelings, and giving them feelings of being valued. However, some situations may need a targeted response to prolonged or intense negative affectivity, or mini-interventions may even (unintentionally) trigger negative instead of positive feelings.

Study design

Facilities were allowed to select care units and providers to include in the study. Therefore, our sample may be a positive selection of motivated and engaged units and providers. We intended to include only RNs as providers, but some facilities also selected unregulated HCAs and other provider groups. However, DEMIAN explicitly focuses on improving communication between care provider groups, as well as among care providers, residents, and family members, so this may have had a positive effect on developing and implementing DEMIAN mini-interventions.

Our study was not optimally powered to find medium to small effect sizes in some outcomes, largely because one facility dropped out of the IG before follow-up assessment at T2. We found marginally significant reductions in job dissatisfaction and significant reductions in time pressure (even after adjusting for the complex, clustered data structure), but only borderline significant effects for more emotion-oriented entries in nursing documentation, and no significant effects in other BHD and TAA-A outcomes.

Outcome measures

While care providers’ job satisfaction and time pressure are important outcomes, as they are critical predictors for quality of care (Knopp-Sihota et al., 2015; Lu, Barriball, Zhang, & While, 2012; Squires, Hoben, Linklater, Carleton, & Estabooks, 2015), they are only proxy measures of quality of care for residents. Important next steps will be rigorous evaluations of the effect of DEMIAN (or similar interventions) on resident outcomes (such as quality of life, or care-sensitive quality indicators such as changed behaviours, social engagement, depressive symptoms, etc.).

Intervention development

We developed the intervention based on theory and research evidence. To develop DEMIAN further, we will systematically use the international knowledge translation literature, for example, literature related to intervention development and mapping (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011; Medical Research Council, 2008). The focus of our study was not to assess the sustained implementation of DEMIAN. We trained care providers on selected units in nine LTC facilities to assess the general feasibility and effectiveness of the intervention. We did not evaluate how trained staff communicated with their colleagues about DEMIAN or how they provided mini-interventions.

Outlook

Our results demonstrate that the DEMIAN intervention is feasible for trained care providers. Our long-term perspective therefore needs to focus on ‘how do we get nurses to agree that we must incorporate making moments matter into our daily work?’ (Pringle, 2003, p. 12). Fostering the ‘quality of the moment’ is just a first step to a culture of person-centred care. As McCormack, Dewing, and McCance (2011) emphasized, we must ‘move from what we suggest are “person-centred moments” (individual, ad hoc experiences of person-centeredness) to “person-centred care” as an underpinning culture of teams and organisations’ (p. 1). Implementing a complex intervention requires an organizational culture change to reach sustainability (McCormack et al., 2010). We have started to develop an implementation concept to apply DEMIAN in a long-term process (cf. Berendonk, Bär, Hoben, & Kruse, 2015). This concept allows a tailored adaption to individual LTC facility contexts instead of completely standardized procedures (Craig et al., 2013).

Research is crucial in other areas, such as comparing strategies to educate care providers on fostering emotional well-being and determining effective steps to derive tailored interventions in LTC settings. In particular, having the HCA workforce plan and apply DEMIAN mini-interventions could be of great value because they are the staff with the most detailed knowledge about and experience with individual residents. Unfortunately they are not always included in care planning steps.

Conclusion

Our study adds an effective tool, the DEMIAN intervention, to person-centred care (Edvardsson et al., 2014; Jeon et al., 2012; McCormack et al., 2010). By applying DEMIAN, care providers were able to provide mini-interventions that support individual well-being of persons with dementia. Trained care providers were able to gather pertinent information on meaningful situations for each resident and derive individual mini-intervention plans in facilitated case conferences. These mini-interventions were carried out multiple times by diverse care providers over our six-week intervention period. We know from our previous study that the mini-interventions are effective in fostering emotional well-being of persons with dementia by creating meaningful situations for them (cf. Bär et al., 2006; Böggemann et al., 2008).

DEMIAN can improve the quality of the moment for persons with dementia and increase scope of action for care providers to improve well-being systematically, as seen in our two consecutive studies in German LTC facilities. DEMIAN is therefore an intervention that supports the implementation of person-centred care strategies. Our results indicate that fostering well-being is a mutual process between care providers and residents, rather than a unidirectional service task that exclusively benefits the care recipient.

Footnotes

Acknowledgements

The authors would like to thank the Nursing Research Network NRW, located at Bielefeld University, for support over the seven-year funding period. Particularly we want to express our gratitude to all persons living with dementia and all care providers for participation. Finally, we would like to express our special thanks to Dr. Andreas Kruse for his leadership on and support of this study and all former research team members for their contributions: Marlies Böggemann, Susanna Re, Silke Stanek, Sonja Ehret, Marion Motruk, and Mechthild Schönit.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was sponsored by the German Federal Ministry of Education and Research (2004–2007 and 2007–2010) (Grant numbers 01GT0318 and 01GT0618).

Notes

Charlotte Berendonk is a registered geriatric nurse and holds a PhD in Gerontology. After completing her doctoral project in 2014, Charlotte has been doing her postdoctoral training in the program ‘Change your view-point’ of the Robert Bosch Stiftung. One of her major research foci is Narrative Care, a nursing philosophy and intervention, strongly based on acknowledging persons as narrative beings.

Roman Kaspar is a psychologist at the Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health, Germany. His main areas of interest are environmental gerontology, quality of life in very old age and dementia, nursing competencies, survey methodology and quantitative data analysis.

Marion Bär holds an undergraduate degree in Music Therapy and a graduate and PhD degree in Gerontology. Her research focus is on quality of life in seniors with dementia and of seniors at very old age. After several years of clinical research at the University of Heidelberg, she has been working since 2011 as a freelance scientist, process consultant for healthcare organizations, and as a publicist.

Matthias Hoben has been trained as a Registered Nurse in Germany and holds a MSc and PhD in Health and Nursing. Since 2014, he has been a Postdoc with the Translating Research in Elder Care (TREC) program, funded by an Alberta Innovates – Health Solutions (AIHS) postdoctoral fellowship. His major research focus is quality improvement and knowledge translation in long term care. Specifically, his research has encompassed topics like developing, translating and validating research tools, improving oral health assessment and practice in long term care, quality of end of life care, association of organizational context and best practice use, development and evaluation of effective strategies to feedback research results into practice, and seniors with multiple chronic diseases.

References

Bär

(2010) Sinn erleben im Angesicht der Alzheimerdemenz – Ein anthropologischer Bezugsrahmen, Marburg: Tectum Verlag.

Bär

Böggemann

Kaspar

Berendonk

Seidl

Schröder

(2006) Demenzkranke Menschen in individuell bedeutsamen Alltagssituationen: Erste Ergebnisse eines Projekts zur Förderung der Lebensqualität durch Schaffung positiver Anregungsmoglichkeiten. Zeitschrift für Gerontologie und Geriatrie 39(3): 173–182. DOI: 10.1007/s00391-006-0384-4.

Bartholomew

L. K.

Parcel

G. S.

Kok

Gottlieb

N. H.

Fernandez

M. E.

(2011) Planning Health Promotion Programs. An intervention mapping approach, 3rd ed. San Francisco: Jossey-Bass. A Wiley Imprint.

Beil, J. (2012). „Die Heimat vergisst man nicht“– Eine qualitative empirische Analyse zu subjektiven Bedeutungen von Orten und Gegenständen im Leben von Menschen mit Demenz. Heidelberg. Dissertation.

Benner, P., & Wrubel, J. (1997). Pflege, Streß und Bewältigung. Gelebte Erfahrung von Gesundheit und Krankheit. Bern: Huber-Verlag.

Berendonk

Bär

Hoben

Kruse

(2015) Von der Intervention zum implementierbaren Konzept: Entwicklungsschritte des DEMIAN-Konzepts. In: Hoben

Bär

Wahl

H.-W.

(eds) Implementierungswissenschaft für Pflege und Gerontologie. Grundlagen, Forschung und Anwendung – Ein Handbuch, Stuttgart: Kohlhammer, pp. 308–320.

Berendonk

Stanek

(2010) Positive Emotionen von Menschen mit Demenz fördern. In: Kruse

(ed.) Lebensqualität bei Demenz? Zum gesellschaftlichen und individuellen Umgang mit einer Grenzsituation im Alter, Heidelberg: Akademische Verlagsgesellschaft, pp. 157–176.

Berendonk

Stanek

Kaspar

Schönit

Bär

Kruse

(2011) Biographiearbeit in der stationären Langzeitpflege von Menschen mit Demenz – Potentiale des DEMIAN-Pflegekonzepts. Zeitschrift für Gerontologie und Geriatrie 44(1): 13–18. DOI: 10.1007/s00391-010-0155-0.

Berendonk

Stanek

Kaspar

Schönit

Kruse

(2010) Emotionales Wohlbefinden von Menschen mit Demenz gezielt fordern: Vom “Bauchgefühl” zum Pflegekonzept. Pflegezeitschrift 63(6): 355–358.

10.

BMJV – Bundesministerium der Justiz und Verbraucherschutz. (1998). Verordnung über personelle Anforderungen für Heime (Heimpersonalverordnung – HeimPersV). Retrieved from www.gesetze-im-internet.de/bundesrecht/heimpersv/gesamt.pdf.

11.

Boelsma

Baur

V. E.

Woelders

Abma

T. A.

(2014) “Small” things matter: Residents' involvement in practice improvements in long-term care facilities. Journal of Aging Studies 31: 45–53. DOI: 10.1016/j.jaging.2014.08.003.

12.

Böggemann

Kaspar

Bär

Berendonk

Kruse

(2008) Positive Erlebnisräume für Menschen mit Demenz: Ein Ansatz zur Förderung von Lebensqualität im Rahmen individuenzentrierter Pflege. In: Schaeffer

Behrens

Görres

(eds) Optimierung und Evidenzbasierung pflegerischen Handelns. Ergebnisse und Herausforderungen der Pflegeforschung, Weinheim: Juventa.

13.

Boller

Verny

Hugonot-Diener

Saxton

(2002) Clinical features and assessment of severe dementia. A review. European Journal of Neurology 9(2): 125–136.

14.

Büssing, A., & Glaser, J. (2002). Das Tätigkeits- und Arbeitsanalyseverfahren – Screening Altenpflege. Retrieved from http://www.psycho.wi.tum.de.

15.

Büssing

Glaser

Höge

(1999) Erfassen und Bewerten psychischer Belastungen bei Beschäftigten im Pflegebereich. Entwicklung eines Screeningverfahrens für den Arbeits- und Gesundheitsschutz im Krankenhaus (Bericht Nr. 49 aus dem Lehrstuhl für Psychologie), München: Technische Universität, Lehrstuhl für Psychologie.

16.

Büssing

Glaser

Höge

Giesenbauer

(2000) Entwicklung eines Screeningverfahrens zur Erfasung psychischer Belastungen bei Beschäftigten im Pflegebereich. Zweiter Zwischenbericht an die Bundesanstalt für Arbeitsschutz und Arbeitsmedizin (BAuA). Bericht Nr. 52 aus dem Lehrstuhl für Psychologie, München: Technische Universität, Lehrstuhl für Psychologie.

17.

Cahill

Diaz-Ponce

A. M.

(2011) ‘I hate having nobody here. I'd like to know where they all are': Can qualitative research detect differences in quality of life among nursing home residents with different levels of cognitive impairment? Aging & Mental Health 15(5): 562–572. DOI: 10.1080/13607863.2010.551342.

18.

Carstensen

L. L.

(1991) Socioemotional selectivity theory: Social activity in life-span context. Annual Review of Gerontology and Geriatrics 11: 195–217.

19.

Cohen

(1988) The concepts of power analysis. In: Cohen

(ed.) Statistical power analysis for the behavioral sciences, Hillsdale, NJ: Lawrence Erlbaum, pp. 1–18.

20.

Cooney

Hunter

Murphy

Casey

Devane

Smyth

O'Shea

(2014) ‘Seeing me through my memories’: A grounded theory study on using reminiscence with people with dementia living in long-term care. Journal of Clinical Nursing 23(23–24): 3564–3574. DOI: 10.1111/jocn.12645.

21.

Cooney

O'Shea

Casey

Murphy

Dempsey

Smyth

Jordan

(2012) Developing a structured education reminiscence-based programme for staff in long-stay care facilities in Ireland. Journal of Clinical Nursing 22(13–14): 1977–1987. DOI: 10.1111/j.1365-2702.2012.04342.x.

22.

Craig

Dieppe

Macintyre

Michie

Nazareth

Petticrew

(2013) Developing and evaluating complex interventions: The new Medical Research Council guidance. International Journal of Nursing Studies 50(2013): 587–592.

23.

de Medeiros

Doyle

P. J.

(2013) Remembering the person in person-centered residential dementia care. Generations – Journal of the American Society on Aging 37(3): 83–86.

24.

Diener

Sandvik

Pavot

(1991) Happiness is the frequency, not intensity of positive versus negative affect. In: Strack

Argyle

Schwarz

(eds) Subjective well-being. An interdisciplinary perspective, Oxford: Pergamon Press, pp. 119–139.

25.

Edvardsson

Fetherstonhaugh

Nay

(2010) Promoting a continuation of self and normality: Person-centred care as described by people with dementia, their family members and aged care staff. Journal of Clinical Nursing 19(17–18): 2611–2618. DOI: 10.1111/j.1365-2702.2009.03143.x.

26.

Edvardsson

Sandman

P. O.

Borell

(2014) Implementing national guidelines for person-centered care of people with dementia in residential aged care: Effects on perceived person-centeredness, staff strain, and stress of conscience. International Psychogeriatrics 26(7): 1171–1179. DOI: 10.1017/S1041610214000258.

27.

Ehret, S. (2008). “Ich werde wieder lebendig”. Personale Geschehensordnung und Daseinsthematische Begleitung bei Menschen mit Demenz. Heidelberg, Dissertation.

28.

Finnema

Dröes

R. M.

Ettema

Ooms

Ader

Ribbe

van Tilburg

(2005) The effect of integrated emotion-oriented care versus usual care on elderly persons with dementia in the nursing home and on nursing assistants: A randomized clinical trial. International Journal of Geriatric Psychiatry 20(4): 330–343. DOI: 10.1002/gps.1286.

29.

Fischer, A. W. (2006). Beanspruchungsmuster im Pflegeberuf. Eine Studie an österreichischem Pflegepersonal im Schnittpunkt von persönlichkeits-, gesundheits- und arbeitspsychologischem Herangehen. Dissertationsschrift, Universität Potsdam.

30.

Glaser, J., Lampert, B., & Weigl, M. (2007). Arbeit in der stationären Altenpflege – Analyse und Förderung von Arbeitsbedingungen, Interaktionen, Gesundheit und Qualität. Abschlussbericht zum Forschungsvorhaben F 1977 zur Vorlage an die Bundesanstalt für Arbeitsschutz und Arbeitsmedizin (Vol. Bericht Nr. 86 aus dem Lehrstuhl für Psychologie). München: Technische Universität, Lehrstuhl für Psychologie.

31.

Gozalo

Prakash

Qato

D. M.

Sloane

P. D.

Mor

(2014) Effect of the bathing without a battle training intervention on bathing-associated physical and verbal outcomes in nursing home residents with dementia: A randomized crossover diffusion study. Journal of the American Geriatrics Society 62(5): 797–804. DOI: 10.1111/jgs.12777.

32.

Hacker

(2009) Arbeitsgegenstand Mensch: Psychologie dialogisch-interaktiver Erwerbsarbeit: Ein Lehrbuch, Lengerich: Pabst Science Publishers.

33.

Hacker

Reinhold

(1999) Beanspruchungsscreening bei Humandienstleistungen: BHD-System, Frankfurt am Main: Harcourt Test Services GmbH.

34.

Han

Radel

McDowd

J. M.

Sabata

(2016) Perspectives of people with dementia about meaningful activities: A synthesis. American Journal of Alzheimer's Disease & Other Dementias 31(2): 115–123. DOI: 10.1177/1533317515598857.

35.

Harmer

B. J.

Orrell

(2008) What is meaningful activity for people with dementia living in care homes? A comparison of the views of older people with dementia, staff and family carers. Aging & Mental Health 12(5): 548–558. DOI: 10.1080/13607860802343019.

36.

Jeon

Y. H.

Luscombe

Chenoweth

Stein-Parbury

Brodaty

King

Haas

(2012) Staff outcomes from the caring for aged dementia care resident study (CADRES): A cluster randomised trial. International Journal of Nursing Studies 49(5): 508–518. DOI: 10.1016/j.ijnurstu.2011.10.020.

37.

Kaspar

Hartig

(2016) Emotional competencies in geriatric nursing: Empirical evidence from a computer based large scale assessment calibration study. Advances in Health Sciences Education 21(1): 105–119. DOI: 10.1007/s10459-015-9616-y.

38.

Knopp-Sihota

J. A.

Niehaus

Squires

J. E.

Norton

P. G.

Estabrooks

C. A.

(2015) Factors associated with rushed and missed resident care in western Canadian nursing homes: A cross-sectional survey of health care aides. Journal of Clinical Nursing 24: 2815–2825. DOI: 10.1111/jocn.12887.

39.

Kontos

P. C.

(2011) Rethinking sociability in long-term care: An embodied dimension of selfhood. Dementia – The International Journal of Social Research and Practice 11(3): 329–346. DOI: 10.1177/1471301211421073.

40.

Kruse, A., Berendonk, C., Stanek, S., Schönit, M., Kaspar, R., Bär, M., … Böggemann, M. (2010). DEmenzkranke Menschen in Individuell bedeutsamen AlltagssituationeN – Handlungskompetenzen in der Betreuung demenzkranker Menschen fördern. Unveröffentlichter Abschlussbericht des BMBF-Projekts mit dem Förderkennzeichen 01GT0618.

41.

Lawton

M. P.

(2001) Emotion in later life. Current Directions in Psychological Science 10(4): 120–123.

42.

Barriball

K. L.

Zhang

While

A. E.

(2012) Job satisfaction among hospital nurses revisited: A systematic review. International Journal of Nursing Studies 49(8): 1017–1038. DOI: 10.1016/j.ijnurstu.2011.11.009.

43.

McCormack

(2004) Person-centredness in gerontological nursing: An overview of the literature. Journal of Clinical Nursing 13(3a): 31–38. DOI: 10.1111/j.1365-2702.2004.00924.x.

44.

McCormack

Dewing

Breslin

Coyne-Nevin

Kennedy

Manning

Slater

(2010) Developing person-centred practice: Nursing outcomes arising from changes to the care environment in residential settings for older people. International Journal of Older People Nursing 5: 93–107. DOI: 10.1111/j.1748-3743.2010.00216.x.

45.

McCormack

Dewing

McCance

(2011) Developing person-centred care: Addressing contextual challenges through practice development. Online Journal of Issues in Nursing 16(2): 1–17. DOI: 10.3912/OJIN.Vol16No02Man03.

46.

McCormack

Roberts

Meyer

Morgan

Boscart

(2012) Appreciating the ‘person' in long-term care. International Journal of Older People Nursing 7(4): 284–294. DOI: 10.1111/j.1748-3743.2012.00342.x.

47.

McDermott

Orell

Ridder

H. M.

(2014) The importance of music for people with dementia: The perspectives of people with dementia, family carers, staff and music therapists. Aging & Mental Health 18(6): 706–716. DOI: 10.1080/13607863.2013.875124.

48.

McKeown

Clarke

Ingleton

Ryan

Repper

(2010) The use of life story work with people with dementia to enhance person-centred care. International Journal of Older People Nursing 5(2): 148–158. DOI: 10.1111/j.1748-3743.2010.00219.x.

49.

Mallidou

A. A.

Cummings

G. E.

Schalm

Estabrooks

C. A.

(2013) Health care aides use of time in a residential long-term care unit: A time and motion study. International Journal of Nursing Studies 50(9): 1229–1239. DOI: 10.1016/j.ijnurstu.2012.12.009.

50.

Mayring, P. (2008). Qualitative Inhaltsanalyse. Grundlagen und Techniken (Vol. 10, Auflage). Weinheim und Basel: Beltz Verlag.

51.

MDS – Medizinischer Dienst des Spitzenverbandes Bund der Krankenkassen e. V. (Ed.). (2012). 3. Bericht des MDS nach § 118 Abs. 4 SGB X – Qualität in der ambulanten und stationären Pﬂege. Köln: Asmuth Druck + Crossmedia Gmbh & Co. Kg.

52.

Medical Research Council. (2008). Developing and evaluating complex interventions: New guidance. Retrieved from www.mrc.ac.uk/complexinterventionsguidance.

53.

Milte

Shulver

Killington

Bradley

Ratcliffe

Crotty

(2016) Quality in residential care from the perspective of people living with dementia: The importance of personhood. Archives of Gerontology and Geriatrics 63(2016): 9–17. DOI: 10.1016/j.archger.2015.11.007.

54.

Naylor

Clare

(2008) Awareness of memory functioning, autobiographical memory and identity in early-stage dementia. Neuropsychological Rehabilitation 18(5/6): 590–606. DOI: 10.1080/09602010701608681.

55.

Pringle

(2003) Making moments matter. CJNR 35(4): 7–13.

56.

(2003) Erleben und Ausdruck von Emotionen bei schwerer Demenz, Hamburg: Dr. Kovac.

57.

Reisberg

Ferris

S. H.

de Leon

M. J.

Crook

(1988) The Global Deterioration Scale (GDS). Psychopharmacology Bulletin 24: 661–663.

58.

Russell

J. A.

Feldman Barrett

(1999) Core affect, prototypical emotional episodes, and other things called emotion: Dissecting the elephant. Journal of Personality and Social Psychology 76(5): 805–819.

59.

Ryan

A. A.

McKenna

(2014) ‘It’s the little things that count’. Families’ experience of roles, relationships and quality of care in rural nursing homes. International Journal of Older People Nursing 10: 38–47. DOI: 10.1111/opn.12052.

60.

Schreiner

A. S.

Yamamoto

Shiotani

(2005) Positive affect among nursing home residents with Alzheimer's dementia: The effect of recreational activity. Aging & Mental Health 9(2): 129–134. DOI: 10.1080/13607860412331336841.

61.

Squires, J. E., Hoben, M., Linklater, S., Carleton, H. L., & Estabooks, C. A. (2015). Job satisfaction among care aides in residential long-term care: A systematic review of contributing factors, both individual and organizational. Nursing Research and Practice 2015, Article ID 157924, 24.

62.

Stanek

Berendonk

Schönit

Kaspar

Kruse

(2010) Individuelle Erlebnisräume für Menschen mit Demenz gestalten. PADUA – Pflege anders denken und ausbilden 5(4): 42–49.

63.

Statistisches Bundesamt. (2015). Pflegestatistik 2013: Pflege im Rahmen der Pflegeversicherung – Deutschlandergebnisse. Retrieved from www.destatis.de.

64.

Strauss

Fagerhaugh

Suczek

Wiener

(1980) Gefühlsarbeit. Ein Beitrag zur Arbeits- und Berufssoziologie. Kölner Zeitschrift für Soziologie und Sozialpsychologie 32: 629–651.

65.

van den Brandt-van Heek

M.-E.

(2011) Asking the right questions: Enabling persons with dementia to speak for themselves. In: Kenyon

Bohlmeijer

Randall

W. L.

(eds) Storying later life. Issues, investigations, and interventions in narrative gerontology, Oxford: University Press, pp. 338–353.

66.

Wahl

H.-W.

Iwarsson

Oswald

(2012) Aging well and the environment: Toward an integrative model and research agenda for the future. The Gerontologist 52(3): 306–316. DOI: 10.1093/geront/gnr154.

67.

Ward

Campbell

Keady

(2014) ‘Once I had money in my pocket, I was every colour under the sun’: Using ‘appearance biographies’ to explore the meanings of appearance for people with dementia. Journal of Aging Studies 30(2014): 64–72. DOI: 10.1016/j.jaging.2014.03.006.

68.

Ward

Vass

A. A.

Aggarwal

Garfiled

Cynyk

(2008) A different story: Exploring patterns of communication in residential dementia care. Ageing & Society 28(2008): 629–651. DOI: 10.1017/S0144686X07006927.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.20 MB