Launching ‘Namaste Care’ in Canada: findings from training sessions and initial perceptions of an end-of-life programme for people with advanced dementia

Abstract

Background

Multisensory approaches and programmes have been developed to improve the quality of both life and dying for people with advanced dementia. However, little is known about the experiences of staff, family and others involved in the use of these programmes, and in the relevant education provided to improve the quality of life of residents living with advanced dementia in long-term care homes.

Aim

The aim of this study was to explore early experiences associated with the implementation of a new programme called ‘Namaste Care’ in two Canadian long-term care homes.

Methods

A multiple methods design was used. This included a survey to evaluate a 2-day education programme and qualitative description of interview data that explored experiences during the first 3 months of implementation.

Results

Survey respondents included 44 long-term care staff and 44 others (primarily family) who had attended a 2-day training session or public lecture. Interviews were undertaken with 18 staff, 5 family members and 2 volunteers to generate qualitative descriptions about the last 3 months of implementation of the 2-day education programme. The majority of those who attended training rated this as excellent and affirmed that they now understood the purpose of ‘Namaste Care’. Most endorsed that they had learned some essentials of ‘Namaste Care’ delivery. The majority of those who attended the public lecture were very satisfied with the education, and better understood how this novel programme could be implemented in long-term care. Qualitative description of interview data revealed that participants were positive about ‘Namaste Care’ in long-term care, and identified both barriers and facilitators to implementation as well as recommendations to help with future implementation.

Conclusions

These study findings support the use of a facility-wide educational programme to help launch a new innovation in long-term care.

Keywords

dementia education long-term care palliative care quality of life

Introduction

The number of residents in long-term care (LTC) with Alzheimer and other progressive dementias is increasing at a rapid rate, driven by a global increase in lifespan, with 35–54% surviving into an advanced stage of the disease (Alzheimer’s Society of Canada, 2010; Stacpoole et al., 2017; Van der Steen et al., 2014). Dementia is a life-limiting disease, with anticipated life expectancy ranging from 3–10 years from the time of diagnosis (Van der Steen, 2010; Zanetti et al., 2009). The Quality End-of-Life Care Coalition of Canada (2010) and the Canadian Hospice Palliative Care Association jointly endorsed a national framework for a palliative approach to care of persons with chronic, progressive, life-limiting illness such as dementia; a seamless transition from chronic disease management to appropriate end-of-life planning and care. Due to the progressing and variable nature of the disease, a dementia-specific palliative approach to care is needed to promote quality of life (Van der Steen et al., 2014). Unfortunately, as dementia progresses residents are often unable to participate in activities provided in LTC for residents in earlier stages (Drinka et al., 2013; Regier et al., 2017). Efforts to promote quality of living and dying for residents with dementia have been neglected, particularly for those with advanced dementia.

A new intervention, called ‘Namaste Care’, has great potential to improve quality of life, dignity and comfort for LTC residents by engaging them in meaningful activities throughout the later stages of the disease trajectory (Simard, 2013; Volicer et al., 2006). ‘Namaste Care’ comes from a Hindu term meaning ‘To honour the spirit within’. It emphasises the dignity that persons with advanced-stage dementia deserve despite their level of ability (Simard and Volicer, 2010). Ideally, this group programme runs 7 days a week, in morning and afternoon sessions, each 2 hours long, with 6–12 residents attending. Two main principles that guide the ‘Namaste Care’ programme are a special environment and a loving touch (Simard and Volicer, 2010). These principles are honoured as care providers engage with the residents and provide meaningful activities such as gentle hand or foot massages, application of a familiar scented lotion and calming music therapy. The programme is primarily supervised by nursing assistants, but family members, other staff in the home and volunteers are encouraged to participate. Initial studies on the effects of ‘Namaste Care’ have shown reduced use of antipsychotics and hypnotics, and decreased behavioural symptoms such as agitation and social withdrawal (Drinka et al., 2013). As well, the implementation of ‘Namaste Care’ has been reported to improve quality of life (Drinka et al., 2013).

Education is beneficial in general for staff working with people at the end of life who require continuous support, mentorship and education, and is particularly important when launching a new programme, such as ‘Namaste Care’ (Cronfalk et al., 2015). Hirakawa et al. (2009) reported that dementia care was one of the most important areas requiring education in LTC. Staff education and awareness of dementia care are critical components to improve quality of care for residents with dementia and their families.

Successful ‘Namaste Care’ programmes require a committed team with support from administration and families in order to promote a positive culture change, with readjustments needed in regular routines and potential reallocation of staff during the initial implementation. Simard and Volicer (2010) suggest that the entire care team should participate in training sessions as this is the first step to being successful in any new implementation. Simard recommends interactive training sessions for staff, including theory of the programme, live demonstration of the activities to take place in the room and a sharing of personal experiences to guide the implementation. Studies have shown that the use of tailored on-site education involving simulation is an effective method for translating knowledge into practice and improving the care of residents in LTC (Parks et al., 2005). Moreover, studies suggest that staff education and appropriate training increase staff confidence in practice, which can greatly impact the quality of care they provide (Frey et al., 2014; Kim and Park, 2017).

Little work has been completed specific to ‘Namaste Care’ training. One study evaluating the ‘Namaste Care’ programme determined that the most powerful element of the initial training was role-modelling of the ‘Namaste Care’ programme with residents and staff (Stacpoole et al., 2014). However, further research is needed to evaluate both ‘Namaste Care’ training sessions as well as its initial implementation from the perspectives of LTC staff and family members.

Aim

The aim of this study was to explore the processes and experiences of launching a new programme, called ‘Namaste Care’, in two LTC homes in two Canadian provinces. Specifically, this study evaluated the initial education programme as well as perceptions during the first 3 months of implementation, from the perspectives of LTC staff, volunteers and family members. This information will be helpful in refining implementation processes to promote success in future work.

Methodology

This study used a multiple method design to address the research objectives. First, we used a cross-sectional survey design that included both quantitative and open-ended questions to evaluate the education programme followed by a qualitative descriptive design to explore initial perceptions of implementing the programme. We considered learning about ‘Namaste Care’ to be more than a one-time event, and anticipated some learning over time and experience, so therefore chose to approach the study in this way. This study was approved by two university-affiliated Research Ethics Boards: the Hamilton Integrated Research Ethics Board (HIREB) and the Saskatchewan Behavioural Research Ethics Board (Beh-REB).

Education programme

The education programme consisted of 8 sessions over a 4-day period for staff as well as an open public lecture for family, friends and others who were interested in the programme, which was held at the LTC home in the evening. Flyers and posters were displayed at each LTC home to inform staff, family and friends about the lecture Additionally, staff were invited by managers of each LTC home to attend the sessions. Content of the sessions for both staff and the public lecture were presented by the ‘Namaste Care’ founder, Joyce Simard, and consisted of a general description of the philosophy and intervention components of the programme, as well as brief case descriptions to emphasise the links between philosophy, intervention components and outcomes. Suggestions to foster successful implementation were also provided. Staff education was supplemented with experiential learning sessions within the ‘Namaste Care’ room, during which small groups of staff provided the programme to residents from the home with live modelling and instruction. Joyce Simard also led all the training sessions. As a further supplement to didactic training sessions, books and other resources (e.g. website, brief nursing journal articles) were also provided to those who expressed interest. The education programme was presented in the same manner with the same number of sessions for both LTC homes.

Setting, sampling and data collection

Immediately after attending the education programme, attendees were asked to complete a survey to assess their overall impressions of the sessions, using closed and open-ended questions. Written consent and surveys were obtained from 44 LTC staff (e.g. personal support workers/care aides (PSWs/CAs), licensed nurses, recreation therapists), 25 in Ontario and 19 in Saskatchewan, and from 44 family members and others, 21 in Ontario and 23 in Saskatchewan.

The survey included five questions that addressed participants’ overall rating of how the education session met their needs, using a Likert scale of 0 (not at all) to 10 (met all of my learning needs), and open-ended questions that addressed their (a) main areas of learning, (b) areas that they liked the most about the education session, (c) areas that they liked least, and (d) suggestions for future sessions related to ‘Namaste Care’.

Analysis and evaluation

Quantitative data was summarised by the lead author (SK) using mean and standard deviation. Both the lead author (SK) and a research assistant (CH) analysed the qualitative data. To do this, content analysis was used to group the data obtained from the open-ended survey questions, which was subsequently analysed using percentages based on the number of responses for each grouping or category.

Initial perceptions of implementing ‘Namaste Care’

Three months after the initial launch of ‘Namaste Care’ (including education sessions), we interviewed key informants in each of the two participating LTC homes to capture their early reactions about implementing the programme. We used purposive sampling to target those who were involved with the implementation, specifically LTC staff, volunteers and family. Using a semi-structured interview guide, questions were asked relating to their initial perceptions and experiences of implementing it, barriers to implementation, and their recommendations for improving the implementation process in future work.

Analysis

Demographic data associated with key informant interviews was summarised using mean and standard deviation (SD) for continuous variables and frequencies, and percentages for categorical variables. Thematic content analysis was used to analyse the interview data. Three members of the research team started by independently coding 3 of the 25 interview transcripts. Once completed, the team met to develop a universal coding scheme based on the initial analysis of the data. The coding scheme consisted of five main codes: general impressions, benefits, facilitators, barriers and recommendations. Within each main code there were various sub-codes (n = 15). The remaining 22 transcripts were then divided between the members and coded to fit the predetermined coding scheme.

Results

Education programme

The average rating of participants’ overall impression of the public lecture with family and others was 9.6 out of 10 (SD = 0.4). Average ratings associated with the education programme for LTC staff were similar, at 9.2 out of 10 (SD = 0.9). The findings for each session (i.e. public lecture and LTC staff training) are reported separately below.

Public lecture for family and others

For the public lecture, many participants (23%) commented on their new learning about ‘Namaste Care’ activities, such as touching, therapeutic responses, human touch, individualised care approach and acknowledging resident presence. Others (16%) commented that they learned more about how the programme sessions are run and the logistics of implementing the programme. One person stated that they learned about possible outcomes of ‘Namaste Care’ (e.g. a reduction in Urinary Tract Infections (UTIs), increase in quality of life and improved opportunities for residents’ social interaction).

There were several comments about what people liked about the presentation. Some participants (25%) commented positively about the guiding philosophy of care. They felt it was very informative and appreciated the presenter Joyce Simard’s enthusiasm and passion towards the programme. Three participants (7%) stated they enjoyed listening to the session, and one was ‘excited to see how the programme rolls out’ and suggested having follow-up sessions with a ‘report back’ about how the programme impacts resident outcomes. Two people mentioned specifically that they were grateful that their loved one had been chosen to participate in the implementation of ‘Namaste Care’ (which began concurrently with the education sessions).

Others suggested areas for improvement (7%), stating that the length of the presentation was too short and they wished it was longer. One person stated that she had misunderstood the topic based on what she had been told, and wished she had invited others to come now that she understood it.

Some of the education topics participants would like to learn about in the future included information on the dying process (9%), progression of dementia (5%), and ‘why those who know that a resident is dying are so scared of preparing family’ (2%). Some participants (7%) stated they would like follow-up information about the LTC homes’ experience with ‘Namaste Care’ as well as its impact on care and how it can be applied to other homes and professions. One person commented: ‘Ideas are great but involve a complete culture change. How to excite staff about possibilities rather than making them feel they have more work to do.’

Training for LTC staff

Similarly, for LTC staff who attended the education session, most participants stated that they now understand the purpose of ‘Namaste Care’ (89%), and how to deliver intervention components during ‘Namaste Care’ sessions, how to interact with residents in the Namaste room and the types of programming offered (80%). In terms of what LTC staff liked the most about the session, 80% liked learning how to reach those residents with advanced dementia, 73% liked the speaker’s energy and passion about ‘Namaste Care’, and 52% reported that they liked learning something. One person mentioned she loved the idea of spending extra time with the residents because she doesn’t normally have this opportunity given the time pressures of her work.

Others (27%) stated that they thought the training was too short. Two people said they would like more information on how the programme will affect staff workload and raised concerns around staff workload and using time efficiently to finish daily duties. One person mentioned they would like ‘spiritual training’ in the future in order to better understand the behaviour of residents with Alzheimer’s. Finally, a participant stated that Namaste will involve a culture change, particularly with the use and misuse of psychotropic medications.

Three-month interviews

The majority of staff and volunteers (95%) who were interviewed were female and the average age was 49.1 (SD = 12.4) years. They had been working with LTC residents with dementia for an average of 13.0 (SD = 11.1) years. Out of the five family members interviewed, three were daughters and two were sons. Family members were on average 58.6 (SD = 9.2) years of age and their loved ones had been residents in LTC for 2.1 (SD = 1.1) years.

General impressions of ‘Namaste Care’

Overall, participants described their general impressions of the ‘Namaste Care’ programme, which became clearer over the first 3 months of implementing it. A nurse described it as follows:

I think it gives one-on-one time with clients. It gives touch, and a quiet, relaxed environment. The chance to give nutrition, which is something we attempt to do but are not always successful at doing it. (Site 2, nurse, page 1)

A PSW/CA elaborated:

I would say it is good care, because they actually get comfort, and feel love and they get to listen to the music or someone just coming to spend a little bit of time. (Site 2, PSW/CA, page 1)

Perceived benefits of the ‘Namaste Care’ programme

Participants described many benefits of ‘Namaste Care’ for those residents who attended the programme. Even in the early stages of implementation, they were beginning to appreciate the benefits of the programme, such as improved mood, more engagement of residents, and individualised care, staff and family becoming more engaged and empowered.

The majority of participants interviewed described how the ‘Namaste Care’ programme appeared to improve residents’ mood. For example, a PSW/CA stated,

I remember the care aides bringing in one resident … they said she was very sad, quiet and very emotional that day. They weren’t sure if she should be there and I said, ‘sure bring her in’ … and I would say after lotioning and talking, and the music going and doing her hair and makeup, she started talking nonstop and she was laughing. By the end of it she was singing out loud with me. (Site 2, PSW/CA, page 2)

Another PSW/CA added,

It is good because it is calm, they calm down and they are actually relaxing and you know giving them time if they feel lonely, so maybe they see that they are like together with some friends. (Site 2, PSW/CA, page 2)

Family members expressed similar comments, stating,

We all seem to agree that mom seems to be less anxious … . I had never seen mom smile like that – this huge big smile on her face. (Site 1, daughter, page 3)

Another family member stated,

But mom enjoyed it and from observing other residents that were involved I could see where they really enjoyed it. Especially when you watched the smiles on their faces, and the enjoyment of the music. Some of them I had never seen them smile before or even had movement and all of a sudden they were tapping their toes and enjoying the music and doing a bit of exercises, and seemed very happy there. (Site 2, daughter, page 1)

A volunteer in the ‘Namaste Care’ room commented on similar observations of residents. This volunteer stated,

The change I’ve seen in her is that she will look you in the eye when you come in the room, and she will smile … I’ve just seen it continue from there. She laughs at us, and she has a smile. She sits with her eyes open and just a calm look on her face. She doesn’t smile all the time but she has her eyes open and she’s pleasant. (Site 2, volunteer, page 4)

Some participants made comments that they felt residents were more alert in the ‘Namaste Care’ room and engaged more with staff and family. A son of a resident stated,

like there seems to be … a higher level of consciousness for the people that are here. Like they seem to be more able to recognize you, talk with you and you know even if they don’t talk but a gesture or whatever they can do. That level seems to be quite a bit higher with those people. I think it’s possibly because they are a little bit more satisfied. (Site 2, son, page 2)

In fact, some family members felt that ‘Namaste Care’ could help eliminate the need for certain medications, now that residents appeared more content and engaged. One family member stated,

And you know I can even see where a lot of the anxiety drugs and stuff that are being given could be cut down a lot, because people are just more settled. (Site 2, son, page 3)

The data also suggests that a major strength of the programme is its flexibility and individualised nature. In an interview, one PSW/CA describes adjusting the activities of the programme to the resident’s needs. She says,

So in Namaste somebody is there doing a foot massage, creaming, giving them extra drink. Some of them are watching the programme on TV and some are … you show them pictures in the book. But the ones that can’t do it, you find different things that they can do. (Site 1, PSW/CA, page 1)

One family member aptly stated that,

There’s not a lot of other activities that she can do because of her dementia and her deafness. It is pretty special I guess that Namaste care is tailored to that type of resident. (Site 1, daughter, page 7)

Another family member adds,

Yeah Namaste Care is so very personalized. Very much so. And I’ve been really impressed. (Site 1, daughter, page 2)

The majority of participants, both staff and family, expressed how participating in the ‘Namaste Care’ programme helped them feel more empowered and engaged in caring for residents who have advanced dementia. A recreation therapist stated,

We give her lots of drinks and she’s really thirsty right? So she can have that need fulfilled. (Site 1, recreation therapist, page 10).

A volunteer added,

Some of them it is a big response, and you feel so connected, like you’re giving back in some way, like you’re giving them something that they value. (Site 2, volunteer, page 5)

A number of family members made similar comments:

Not like under pressure. I can come every other day and not feel bad, ’cause I know she has this going on. (Site 2, daughter, page 6)

I can see that it’s very helpful. It’s something I would like to see continue. I think, wow, if I get to this point I would like something like this to be in place. I go away from here feeling such joy, you know? It’s not all about me but I’m getting the joy from just doing and helping. I can see that it’s making a difference. When you get a smile from somebody that is so sweet. (Site 2, daughter, page 4)

I’ve only been doing it the 4 weeks, and I find that I usually get up excited in the morning to come, even the first day. I didn’t even know what to really expect, but it is something that seems to touch my heart to be able to help out this way. (Site 2, daughter, page 1)

Facilitators to implementing ‘Namaste Care’

Participants stated that having strong support from administration as well as good communication helped to facilitate the implementation of ‘Namaste Care’. In particular, the staff leads or champions for the programme, who were usually nurses or managers, helped facilitate the organisation and management of the programme on a daily basis to help it run smoothly. One nurse says,

Oh the staff comes to me and tells me there’s nobody in the room so I have to organise with the staff who is willing to go and who is willing to stay on the floor. So we talk, like the team on the first floor we talk about who can go. (Site 1, nurse, page 2)

Barriers to implementing ‘Namaste Care’

However, some barriers to implementing the programme existed, such as the extra burden it placed on staff, the timing and length of the programme, and reported adverse events.

One reoccurring barrier to ‘Namaste Care’ that was brought up was staff burden over time. This involved the fact that the programme does not require any extra staffing, simply redistribution of staff members. Many staff members, including recreation therapists, identified that they felt they were already overworked and didn't have enough time to do any more. The PSWs/CAs didn’t like to leave their co-workers on the floor alone while they went to ‘Namaste Care’, for safety reasons (i.e. transferring some residents requires two people) and for fear that they were neglecting the other residents in the home.

It’s really really busy in the morning that we usually find it hard for us because you can’t be alone and we still have people in bed and you have to wait for the other side to get help, but the other side maybe they are still busy too you know. That’s the struggle that we have right now. (Site 2, PSW/CA, page 1)

Being that is a very busy time of the morning, and getting people there you know with the care aides it is hard to get people there in the morning, and we don’t have the staff. (Site 2, recreation therapist, page 1)

There have been families that have complained … that they don’t like their people not getting enough attention, because someone has gone off the floor. (Site 2, PSW/CA, page 3)

Many of the nursing staff identified they were not as involved as they would have liked to be because they were worried about liability issues if they left their work to attend sessions.

The care needs now are much, much heavier than they were 10 years ago …, I think there are many staff that are almost overwhelmed in their day-to-day responsibilities without Namaste. (Site 2, nurse, page 3)

Another barrier or challenge that participants described was related to adverse events such as incidence of skin breakdown. This issue was raised at both sites:

When we initially started putting residents in there and they went for the four hours a day. Those residents who had maybe previous ulcers, re opened. (Site 1, director of care, page 2)

Well it doesn’t hurt them, the residents. Except there are some that can’t go twice a day because they have skin break down, I mean they just can’t handle it body wise. (Site 2, PSW/CA, page 3)

Recommendations to implement ‘Namaste Care’ in new LTC homes

A number of recommendations were suggested to improve the implementation of ‘Namaste Care’ in the future. Some participants expressed concerns about how the programme was launched in their LTC home and suggested a more informed, collaborative and coordinated approach for the future. A nurse stated,

I don’t know if the approach initially was very positive, because it was just kind of thrown at them. (Site 2, nurse, page 2)

Another nurse expressed similar sentiments, stating:

I wish that before we brought in Namaste we would have talked about it and gotten a core group of people together and learned about the knowledge and were able to participate and who would be participating in it. (Site 2, nurse, page 6)

Others recommended that key staff should assume the role of a champion to help lead and organise the programme in a positive and constructive manner. A participant stated,

I almost wonder if there should be a ‘Namaste Care’ specialist. Like you know someone who takes the lead on the programme and runs the programme. (Site 1, recreation therapist, page 11)

Many of the participants voiced their concern about the home being regularly understaffed and stated that they would like more funding and resources to run the programme. A family member stated,

I think there would be a need for more staff or at least more volunteers because I think it would be manageable with the appropriate amount. (Site 2, daughter, page 3)

Similar statements were brought forward by staff, and one PSW/CA stating,

If we could have funding for someone to be in there I would definitely be on the waiting list to try and apply for that position. (Site 2, PSW/CA, page 4)

Other recommendations included using brighter and bigger rooms for ‘Namaste Care’,

since wheelchairs are so big and it’s kind of crowded cause we are in a circle and stuff. (Site 2, PSW/CA, page 4)

Finally, a family member suggested that

If somebody is really agitated maybe to remove them so the others don’t get agitated. (Site 2, daughter, page 2)

Discussion

This study contributed to our knowledge about the processes and experiences with the initial launch of the ‘Namaste Care’ programme in two LTC homes in Canada, which may inform future implementation of ‘Namaste Care’ to other settings. These findings add to the growing body of literature that supports the implementation of ‘Namaste Care’ as an innovative programme to help improve the quality of life for residents who have advanced dementia and are nearing the end of their lives.

Our study findings highlighted a number of ‘positive moments’ where both family and staff described residents’ mood as improved during and after attending ‘Namaste Care’. These moments, including residents speaking, being more interactive, smiling, not seeming depressed or ‘emotionally hurt’ have been reported in other ‘Namaste Care’ research as well (McNeil and Westphal, 2018). McNeil and Westphal (2018) also found that ‘Namaste Care’ decreased restlessness, anxiety, noticeable changes in personality and behavioural changes. Future research is needed to examine the effectiveness of ‘Namaste Care’ on these outcomes using quantitative methods to determine measures such as duration of the effect or number of participants who experienced the effect.

There is little evidence in the literature about the decision to hold ‘Namaste Care’ in the morning and afternoon (Simard and Volicer, 2010). However, the literature on timing interventions for LTC residents with dementia seems to support this notion. That is, it has been noted that agitation and disruptive behaviours appear to peak later in the day (Burgio et al., 2001; Cohen-Mansfield, 2007; McCann et al., 2004). Moreover, Cohen-Mansfield et al. (2010) identified that engagement, duration and attention in nursing home residents with dementia were found to be significantly greater in the afternoon than in the morning. While further research is needed on the effects of timing with ‘Namaste Care’ as an intervention in order to be more certain, previous studies that report on ‘Namaste Care’ studies support this timing.

Our study findings show that ‘Namaste Care’ allows for continual attention to the quality of life of residents even as their dementia advances. This sense of adaptability allows residents who do not normally meet inclusion criteria for more structured programming, even for those with dementia, to get meaningful attention and stimulation. Simard and Volicer (2010) explain that nursing home residents with advanced-stage dementia are typically left ‘slumped in chairs’ (p. 46) or sleeping through other recreational programmes that they are brought to. The Registered Nurses Association of Ontario (2016) recommend that care for people with advanced dementia should be individualised based on (a) the person’s preferences and interests, (b) the person’s behavioural and psychological symptoms, and (c) the person’s needs and abilities. As well, The Alzheimer Society of Canada (2011: 7) supports the belief that ‘people with dementia have the right to enjoy the highest possible quality of life and quality of care by being engaged in meaningful relationships which are based on equality, understanding, sharing, participation, collaboration, dignity, trust and respect’.

Our study findings are consistent with other research, highlighting that staff experience stress and burden when implementing new innovations, especially those that require a shift in their daily activities (Hazelhof et al., 2016; Kennedy, 2005; Zwijsen et al., 2014). When exploring other ‘Namaste Care’ studies, not many focused their research on the impact of the programme on staff members. One study by Stacpoole et al. (2015) used an action research design to investigate the effects of the programme on six different LTC homes. Similar to our findings, they also acknowledged that strong leadership and adequate staffing must already be in place for the ‘Namaste Care’ programme to succeed (Stacpoole et al., 2015). However, they found that the effectiveness of the intervention declined towards the end of their study, which they attributed to staff investing less energy in the programme after their initial interest (Stacpoole et al., 2015). Further work is needed to explore the sustainability of the programme over a longer period of time.

Findings from our study emphasise the need to include staff in all aspects of programme implementation, particularly in the early stages, in order to promote an engaged and team approach to implementing ‘Namaste Care’. In another study, Simard (2007) described how staff were introduced to the programme by educational sessions and afterwards they could apply to their supervisors if they were interested in taking responsibility for its implementation. Staff members who took part were also included in the design of the programme and selection of the residents (Simard, 2007). This inclusion allowed them to feel that their opinions were valued which helped their support towards the programme (Simard, 2007). Participants in our study affirmed this by recommending that when launching ‘Namaste Care’, staff should be involved in decision making to adjust the programme launch and have more choice in its design and the selection of residents who would be appropriate for it.

Limitations of study

This study has limitations. First, the small sample and its geographical location may limit its generalisability to other LTC homes and regions. Second, since our results are based on perceptions of study participants, more research is needed to examine objective outcomes in order to adequately assess its effectiveness.

Conclusion

These study findings support the use of a facility-wide educational programme to help launch a new innovation in LTC, such as ‘Namaste Care’. Initial perceptions of this programme were positively regarded by LTC staff and residents’ family members; they felt that it improved the quality of life for residents. However, staff involvement in both the implementation and decision making around it is recommended, in order to facilitate a collaborative approach.

Key points for policy, practice and/or research

Impact of ‘Namaste Care’ on residents in LTC: Positive impacts on residents shown through this study can be used as evidence for future programming for persons with advanced dementia. Future research work may also be guided by the impact of ‘Namaste Care’ on residents in LTC.

Importance of continual attention to the quality of life of residents with advance d-stage dementia: The ‘Namaste Care’ programme aligns with both provincial and national guidelines for dementia care to reiterate that residents with advance d-stage dementia need attention. This finding can be used to guide nursing practice and future research that focuses on the quality of life of this population.

Staff stress and burden when implementing new innovations: This study shows that implementing new innovations that require a shift in daily activities for staff in LTC can result in stress and burden. This finding and related literature can guide healthcare practice and future work related to programme implementation in LTC.

Including staff in the implementation process: This study shows that an engaged team approach is important during programme implementation. Including staff in decision making, programme design and logistics is recommended. This finding can be helpful in guiding future research and implementation projects.

Footnotes

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.

Ethics

This study was approved by two university-affiliated Research Ethics Boards: the Hamilton Integrated Research Ethics Board (HIREB) and the Saskatchewan Behavioural Research Ethics Board (Beh-REB).

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/ or publication of this article: This research was funded by the Alzheimer's Society of Canada from 2015-2017.

Sharon Kaasalainen, is a Professor in the School of Nursing at McMaster University, an associate member of the Department of Family Medicine at McMaster, and an Honorary Professor at Queen’s University in Belfast. Her top three research interests are pain management and palliative care in LTC; improving the quality of life for older adults living in LTC; and advanced practice nursing roles in LTC.

Paulette V Hunter, is an Associate Professor of Psychology at the University of Saskatchewan (St. Thomas More College). Her programme of research emphasises understanding and promoting quality of life in older adulthood, especially among individuals with acquired cognitive disabilities.

Courtney Hill, graduated from McMaster in 2015 with a Bachelor of Science in Nursing degree. Since then she has been working as a full-time Research Coordinator for the School of Nursing. Through her contribution to various research projects, Courtney has expanded her knowledge in improving quality of life for older adults with advanced-stage dementia. Courtney plans to further her understanding in such areas through continuous learning and involvement in future research.

Rachel Moss, is a fourth-year undergraduate student at McMaster University in the Bachelor of Science in Nursing (BScN) programme. She was involved in the data analysis for this study as part of her research practicum course. Through her involvement in the Namaste Care project, she hopes to expand her knowledge around caring for older adults with advanced-stage dementia.

Joy Kim, is a fourth-year undergraduate nursing student at McMaster University in the Bachelor of Science in Nursing (BScN) programme. She contributed to the analysis component of this study as part of her research practicum under the supervision of Dr Sharon Kaasalainen. Her involvement in the Namaste Care project has allowed her to expand her knowledge in caring for older adults with advanced-stage dementia.

Jenny T van der Steen, is an epidemiologist working at Leiden University Medical Centre in the field of end-of-life care, in particular palliative care for nursing home residents with dementia. Her research includes nationwide observational and intervention studies in patients with dementia and pneumonia. Other main areas of her expertise include research methodology, pain assessment, infectious diseases and palliative medicine.

Vanina Dal-Bello Haas, is an Associate Professor in the School of Rehabilitation Sciences and Assistant Dean of Physiotherapy at McMaster University. Her research interests include older adults and individuals with neurodegenerative diseases, therapeutic interventions that maximise function and quality of life along the ageing continuum, and educational research and strategies to increase the capacity of healthcare professionals interested in working with older adults and neurologic populations.

Thomas Hadjistavropoulos, holds a Research Chair in Ageing and Health at the University of Regina and is also a professor in the Department of Psychology. Some of Dr Hadjistavropoulos’ research interests include health psychology, ageing, fear and anxiety in older persons, clinical psychology, and professional ethics and standards.

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